Provider Demographics
NPI:1023175635
Name:MATTERN, ALLAN LEE I (MD)
Entity type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:LEE
Last Name:MATTERN
Suffix:I
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 1:111 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2434
Mailing Address - Country:US
Mailing Address - Phone:307-358-7300
Mailing Address - Fax:
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3059A174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY304480OtherBLUE SHIELD
WY060025397OtherRR MCARE - WCPS
WY060040677OtherRAILROAD MEDICARE
WY102651800Medicaid
WY060025397OtherRR MCARE - WCPS
WY102651800Medicaid