Provider Demographics
NPI:1306833124
Name:MATTHIESSEN, PATRICK M (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:M
Last Name:MATTHIESSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 COMMERCE CROSSINGS DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:1009 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9142
Practice Address - Country:US
Practice Address - Phone:502-222-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074910A2084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN915174OtherANTHEM
KY50084197OtherPASSPORT
KY7100347060Medicaid
IN201274940Medicaid
IN7494410OtherAETNA
KY50084197OtherPASSPORT
IN201274940Medicaid