Provider Demographics
NPI:1023062130
Name:MATTISON, GREGG R (MD)
Entity type:Individual
Prefix:DR
First Name:GREGG
Middle Name:R
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 1:2200 RANDALLIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4638
Mailing Address - Country:US
Mailing Address - Phone:260-373-4731
Mailing Address - Fax:
Practice Address - Street 1:3707 NEW VISION DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46895-5602
Practice Address - Country:US
Practice Address - Phone:260-471-9466
Practice Address - Fax:260-484-5919
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN351882085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092615OtherANTHEM
OH2100630Medicaid
MI4074924100Medicaid
IN1554OtherPHP
IN147380NMedicare ID - Type Unspecified
IN055740HMedicare ID - Type Unspecified
IN924750OMedicare ID - Type Unspecified
IN1554OtherPHP
IN190320LMedicare ID - Type Unspecified
IN194930IMedicare ID - Type Unspecified
IN000000092615OtherANTHEM
OH2100630Medicaid
INB44955Medicare UPIN
MI4074924100Medicaid