Provider Demographics
NPI:1134132517
Name:MATTSON, CLAY S (OD)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:S
Last Name:MATTSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LANTANA PARK
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-5130
Mailing Address - Country:US
Mailing Address - Phone:859-881-5444
Mailing Address - Fax:859-881-3180
Practice Address - Street 1:1024 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2311
Practice Address - Country:US
Practice Address - Phone:859-881-5444
Practice Address - Fax:859-881-3180
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1494DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000380440OtherBLUE CROSS BLUE SHIELD
KY770000735Medicaid
KY770000735Medicaid
KY0960204Medicare PIN