Provider Demographics
NPI:1740323047
Name:MATTISON, GERALD G (OD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:G
Last Name:MATTISON
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 1:206 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-2627
Mailing Address - Country:US
Mailing Address - Phone:518-584-2620
Mailing Address - Fax:518-584-3979
Practice Address - Street 1:206 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-2627
Practice Address - Country:US
Practice Address - Phone:518-584-2620
Practice Address - Fax:518-584-3979
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004160-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00816211Medicaid
NY04700110004OtherDME
NY00816211Medicaid
NY0470010001OtherDME
NYCC3408Medicare ID - Type Unspecified
NYCC9551Medicare PIN
NYCC9554Medicare ID - Type Unspecified
NY04700110004OtherDME