Provider Demographics
NPI:1972235166
Name:MATTIS, ISAAC J
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:J
Last Name:MATTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STANBERRY
Mailing Address - State:MO
Mailing Address - Zip Code:64489-1358
Mailing Address - Country:US
Mailing Address - Phone:660-783-2192
Mailing Address - Fax:660-783-2616
Practice Address - Street 1:202 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STANBERRY
Practice Address - State:MO
Practice Address - Zip Code:64489-1358
Practice Address - Country:US
Practice Address - Phone:660-783-2192
Practice Address - Fax:660-783-2616
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2864207Q00000X
MO2025032839207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine