MEDICARE: KEVIN M MATTESON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	DR.0039709	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407853013
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN M MATTESON M.D.

Provider Business Mailing Address
First Line	:	1311A N MILDRED RD
Second Line	:
City	:	CORTEZ
State	:	CO
Zip	:	81321-2231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311A N MILDRED RD
Second Line	:	STE A
City	:	CORTEZ
State	:	CO
Zip	:	81321-2231
Country	:	US
Telephone Number	:	970-564-2681
Fax Number	:	970-564-2682

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2005
Last Update Date	:	11/27/2023

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