MEDICARE: DR. THOMAS RANDOLPH MATTISON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	E8700	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174633150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS RANDOLPH MATTISON MD

Provider Business Mailing Address
First Line	:	410 N UTICA AVE
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79416-3035
Country	:	US
Telephone Number	:	806-776-1098
Fax Number	:	806-771-2078

Provider Business Practice Location Address
First Line	:	410 N UTICA AVE
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79416-3035
Country	:	US
Telephone Number	:	806-776-1098
Fax Number	:	806-771-2078

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/31/2013

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