Provider Demographics
NPI:1174633150
Name:MATTISON, THOMAS RANDOLPH (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:RANDOLPH
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 1:410 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3035
Mailing Address - Country:US
Mailing Address - Phone:806-776-1098
Mailing Address - Fax:806-771-2078
Practice Address - Street 1:410 N UTICA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3035
Practice Address - Country:US
Practice Address - Phone:806-776-1098
Practice Address - Fax:806-771-2078
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8700207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ44711Medicaid
NMMD2006-0026Medicaid
CODR.0051861Medicaid
NY262998-1Medicaid
TXE8700Medicaid
TXB24662Medicare UPIN