Healthcare Provider Details

I. General information

NPI: 1649700782
Provider Name (Legal Business Name): CHRISTOPHER DAVID MATTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E SUPERIOR ST FL 10
CHICAGO IL
60611-4494
US

IV. Provider business mailing address

420 E SUPERIOR ST FL 10
CHICAGO IL
60611-4494
US

V. Phone/Fax

Practice location:
  • Phone: 402-540-3724
  • Fax:
Mailing address:
  • Phone: 402-540-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.070733
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036.156264
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.156264
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: