Provider Demographics
NPI:1942288493
Name:MATTSON, MILES J (MD)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:J
Last Name:MATTSON
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 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-4821
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 249
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-7780
Practice Address - Fax:906-225-4893
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041253208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2794971Medicaid
MIMM041253OtherBCBSM
MIB47696Medicare UPIN
MIMM041253OtherBCBSM