Provider Demographics
NPI:1063529311
Name:MATTSON, ANNE MARIE (OD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:MATTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:MARIE
Other - Last Name:TAYLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-0564
Mailing Address - Country:US
Mailing Address - Phone:503-656-9477
Mailing Address - Fax:
Practice Address - Street 1:12100 SE STEVENS CT
Practice Address - Street 2:SUITE 106
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-8707
Practice Address - Country:US
Practice Address - Phone:503-653-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2731ATI152W00000X
WA3510152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist