Healthcare Provider Details

I. General information

NPI: 1205089422
Provider Name (Legal Business Name): DONALD ROGER MATTISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROSEBUD IHS HOSPITAL SOLDIER CREEK ROAD
ROSEBUD SD
57570-0400
US

IV. Provider business mailing address

PO BOX 400 SOLDIER CREEK ROAD
ROSEBUD SD
57570-0400
US

V. Phone/Fax

Practice location:
  • Phone: 605-747-2231
  • Fax: 605-747-2216
Mailing address:
  • Phone: 605-747-2231
  • Fax: 605-747-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0061516
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: