Provider Demographics
NPI:1043250939
Name:MATTISON, HERBERT REID (MD)
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:REID
Last Name:MATTISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE.
Practice Address - Street 2:SUITE 750
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1270
Practice Address - Country:US
Practice Address - Phone:317-962-0953
Practice Address - Fax:317-962-2455
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039266A207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100102960Medicaid
IN095700 JMedicare PIN
IN100102960Medicaid
IN264430374Medicare PIN
IN100102960 AMedicaid