Provider Demographics
NPI:1407853013
Name:MATTESON, KEVIN M (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:MATTESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1311A N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311A N MILDRED RD
Practice Address - Street 2:STE A
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2231
Practice Address - Country:US
Practice Address - Phone:970-564-2681
Practice Address - Fax:970-564-2682
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0039709208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40984567Medicaid
CO40984567Medicaid
COG06470Medicare UPIN