Healthcare Provider Details

I. General information

NPI: 1083723902
Provider Name (Legal Business Name): BARBARA GAVIN MATTOX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 12TH STREET JOHN UMSTEAD HOSPITAL
BUTNER NC
27509
US

IV. Provider business mailing address

517 W AYCOCK ST
RALEIGH NC
27608-2511
US

V. Phone/Fax

Practice location:
  • Phone: 919-575-2432
  • Fax:
Mailing address:
  • Phone: 919-341-2008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: