Healthcare Provider Details

I. General information

NPI: 1205008489
Provider Name (Legal Business Name): RICHARD MATTISON, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 ROSWELL RD NE SUITE #116
ATLANTA GA
30342-4432
US

IV. Provider business mailing address

3833 ROSWELL RD NE SUITE #116
ATLANTA GA
30342-4432
US

V. Phone/Fax

Practice location:
  • Phone: 404-812-0211
  • Fax: 404-812-9011
Mailing address:
  • Phone: 404-812-0211
  • Fax: 404-812-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number011627
License Number StateGA

VIII. Authorized Official

Name: DR. RICHARD CRAWFORD MATTISON
Title or Position: OWNER
Credential: MD, FACS
Phone: 404-812-0211