Healthcare Provider Details

I. General information

NPI: 1609828003
Provider Name (Legal Business Name): BRIAN D MATTESON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST #280
BOISE ID
83702-6100
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-6545
  • Fax: 208-345-1213
Mailing address:
  • Phone: 208-345-6545
  • Fax: 208-345-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberM-9277
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: