Healthcare Provider Details

I. General information

NPI: 1912977125
Provider Name (Legal Business Name): TIMOTHY MATTISON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD BLDG H100
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

2006 HOODS CREEK DR
NEW BERN NC
28562-9130
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0102201360
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2019-01943
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: