MEDICARE: DR. MICHAEL TRAE MATTISON M.D.

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	K4741	TX
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	52120	TN

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	8K3321	OTHER	TX	BLUE CROSS BLUE SHIELD
4	113365100	OTHER	TX	FIRSTCARE

General Provider Information

NPI Number	:	1952411977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL TRAE MATTISON M.D.

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	:	02/26/2026

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