Provider Demographics
NPI:1881652204
Name:MATTI, FREDERICK L (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:L
Last Name:MATTI
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 1:2780 HITCHING POST DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-6155
Mailing Address - Country:US
Mailing Address - Phone:786-621-3900
Mailing Address - Fax:
Practice Address - Street 1:1200 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5868
Practice Address - Country:US
Practice Address - Phone:786-621-3900
Practice Address - Fax:307-875-8800
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7199A2085R0202X
FL876152085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120672900Medicaid
WY120672900Medicaid
I10355Medicare UPIN