Provider Demographics
NPI:1578561445
Name:MATTISON, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MATTISON
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 1:5757 MONCLOVA RD
Mailing Address - Street 2:STE 15
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-887-5833
Mailing Address - Fax:419-887-5835
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:STE 15
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-887-5833
Practice Address - Fax:419-887-5835
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2013-01-07
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OH35070695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000344553OtherANTHEM
OH2291407Medicaid
OHP00138896OtherRAILRAOD MEDICARE
OH000000344553OtherANTHEM
OHP00138896OtherRAILRAOD MEDICARE