Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RI0200X | Infectious Disease | 01039266A | IN |
NPI | 1043250939 |
---|---|
Provider Name | Herbert Reid Mattison |
First Address | Indianapolis, IN 46219-4959 |
Second Address | Indianapolis, IN 46202-1270 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2006 |
Last Update Date | 15/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100102960 | (05) | IN |
C58289 | (02) | IN |