Provider Demographics
NPI:1346253580
Name:MATTSON, JON ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:ROBERT
Last Name:MATTSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5830 NW BARRY RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154-2778
Mailing Address - Country:US
Mailing Address - Phone:816-880-6200
Mailing Address - Fax:816-880-6206
Practice Address - Street 1:5830 NW BARRY RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64154-2778
Practice Address - Country:US
Practice Address - Phone:816-880-6200
Practice Address - Fax:816-880-6206
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165578204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOW05000001OtherMEDICARE PTAN-HOSPITAL
MO502240708Medicaid
MOT92000001OtherMEDICARE PTAN CLINIC
MO502240708Medicaid
H46529Medicare UPIN