Provider Demographics
NPI:1952411977
Name:MATTISON, MICHAEL TRAE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TRAE
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 1:410 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3035
Mailing Address - Country:US
Mailing Address - Phone:806-776-1098
Mailing Address - Fax:806-771-2078
Practice Address - Street 1:410 N UTICA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3035
Practice Address - Country:US
Practice Address - Phone:806-776-1098
Practice Address - Fax:806-771-2078
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4741207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98574213Medicaid
TX165107702Medicaid
TX8K3321OtherBLUE CROSS BLUE SHIELD
TX113365100OtherFIRSTCARE
TXP00066256Medicare PIN
TXP23712Medicare UPIN
NM98574213Medicaid