Healthcare Provider Details

I. General information

NPI: 1215048442
Provider Name (Legal Business Name): DOUGLAS MATTOX M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 PEACHTREE ST NE DEPT OF
ATLANTA GA
30308-2247
US

IV. Provider business mailing address

1365A CLIFTON RD NE DEPARTMENT OF OTOLARYNGOLOGY - HEAD AND NECK SURGERY
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3381
  • Fax: 404-778-4295
Mailing address:
  • Phone: 404-778-3381
  • Fax: 404-778-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number45291
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number45291
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: