Provider Demographics
NPI:1356648414
Name:PAUL MATTOX MD PC
Entity Type:Organization
Organization Name:PAUL MATTOX MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-375-2111
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81302-0478
Mailing Address - Country:US
Mailing Address - Phone:970-375-2111
Mailing Address - Fax:970-375-2444
Practice Address - Street 1:501 AIRPORT DR
Practice Address - Street 2:SUITE 263
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2652
Practice Address - Country:US
Practice Address - Phone:970-375-2111
Practice Address - Fax:970-375-2444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM99852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807373Medicare PIN