Healthcare Provider Details

I. General information

NPI: 1114555182
Provider Name (Legal Business Name): MATTHEW RAYMOND LUSSIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MATLOCK RD
MANSFIELD TX
76063-9164
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 817-453-5437
  • Fax:
Mailing address:
  • Phone: 682-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU3928
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: