Healthcare Provider Details

I. General information

NPI: 1821191040
Provider Name (Legal Business Name): RICHARD W MATTISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 KINGSTON PIKE STE 7&8
FARRAGUT TN
37934-2865
US

IV. Provider business mailing address

1275 DICK LONAS RD
KNOXVILLE TN
37909-1382
US

V. Phone/Fax

Practice location:
  • Phone: 865-675-1953
  • Fax: 865-675-0877
Mailing address:
  • Phone: 865-584-4747
  • Fax: 865-584-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60993
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: