Provider Demographics
NPI:1225000706
Name:MATTACOLA, CARL G (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:G
Last Name:MATTACOLA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INDIGO FARM
Mailing Address - Street 2:2282 DANVILLE ROAD
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330
Mailing Address - Country:US
Mailing Address - Phone:859-323-1100
Mailing Address - Fax:859-323-6003
Practice Address - Street 1:900 SOUTH LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-1100
Practice Address - Fax:859-323-6003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT400246Z00000X
KYAT 400246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other