Provider Demographics
NPI:1790830693
Name:MATTOX FAMILY PHYSICIANS, INC
Entity Type:Organization
Organization Name:MATTOX FAMILY PHYSICIANS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MATTOX
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:260-665-2646
Mailing Address - Street 1:3250 INTERTECH DR STE A
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-7224
Mailing Address - Country:US
Mailing Address - Phone:260-665-2646
Mailing Address - Fax:260-665-8707
Practice Address - Street 1:3250 INTERTECH DR STE A
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-7224
Practice Address - Country:US
Practice Address - Phone:260-665-2646
Practice Address - Fax:260-665-8707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052822A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200317780Medicaid
INH26997Medicare UPIN
IN200317780Medicaid
IN4374190001Medicare NSC