1609839091 NPI number — MELANIE DANIELLE MATTSON MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609839091 NPI number — MELANIE DANIELLE MATTSON MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

MATTSON

Provider First Name:

MELANIE

Provider Middle Name:

DANIELLE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

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:

1609839091

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/14/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

220 CAMPUS BLVD STE 100

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

WINCHESTER

Provider Business Mailing Address State Name:

VA

Provider Business Mailing Address Postal Code:

22601-2896

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

540-536-5100

Provider Business Mailing Address Fax Number:

540-536-0235

Provider First Line Business Practice Location Address:

1880 AMHERST STREET

Provider Second Line Business Practice Location Address:

SUITE 100 AND SUITE 200

Provider Business Practice Location Address City Name:

WINCHESTER

Provider Business Practice Location Address State Name:

VA

Provider Business Practice Location Address Postal Code:

22601

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

540-662-0306

Provider Business Practice Location Address Fax Number:

855-264-2066

Provider Enumeration Date:

04/08/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0000X , with the licence number:  0101642786 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 412529100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
• Identifier: 006012124 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 0075072000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 2119642 . This is a "MAMSI PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
• Identifier: 100465 . This is a "ANTHEM PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
• Identifier: 44155 . This is a "SENTARA PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
• Identifier: C00085 . This is a "VA MEDICARE GROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
• Identifier: P00656342 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
• Identifier: 000553833 . This is a "WV BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 08247400000 . This is a "QUALCHOICE PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
• Identifier: 3810003817 . This is a "WV MEDICAID GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
• Identifier: 550941600 . This is a "MD MEDICARE GROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".