Provider Demographics
NPI:1710040522
Name:MATTSON, LOUISE ANN (MD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:ANN
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:1414 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2824
Practice Address - Country:US
Practice Address - Phone:651-772-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95417Medicare UPIN