Provider Demographics
NPI:1982696076
Name:MATTSSON, CARL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:ANTHONY
Last Name:MATTSSON
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 1:4403 HARRISON BLVD
Mailing Address - Street 2:STE 2600
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-2600
Mailing Address - Fax:801-387-2625
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 2600
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2600
Practice Address - Fax:801-387-2625
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT155171-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4360680001OtherCIGNA DMERC
UT04710Medicaid
4053OtherDESERET MUTUAL
UT04710Medicaid