1356648414 NPI number — PAUL MATTOX MD PC

Table of content: (NPI 1356648414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356648414 NPI number — PAUL MATTOX MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL MATTOX MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356648414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81302-0478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-375-2111
Provider Business Mailing Address Fax Number:
970-375-2444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 AIRPORT DR
Provider Second Line Business Practice Location Address:
SUITE 263
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-2652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-375-2111
Provider Business Practice Location Address Fax Number:
970-375-2444
Provider Enumeration Date:
02/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MATTOX
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-375-2111

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  9985 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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