Provider Demographics
NPI:1184811382
Name:MATTSON, MICHAEL DANE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DANE
Last Name:MATTSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209 83RD ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-8747
Mailing Address - Country:US
Mailing Address - Phone:253-841-0602
Mailing Address - Fax:
Practice Address - Street 1:3500 S MERIDIAN
Practice Address - Street 2:# 900 SEARS OPTICAL
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374
Practice Address - Country:US
Practice Address - Phone:253-770-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1380152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist