Provider Demographics
NPI:1215048442
Name:MATTOX, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MATTOX
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 1:1365A CLIFTON RD NE
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY - HEAD AND NECK SURGERY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-3381
Mailing Address - Fax:404-778-4295
Practice Address - Street 1:550 PEACHTREE ST NE DEPT OF
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2247
Practice Address - Country:US
Practice Address - Phone:404-778-3381
Practice Address - Fax:404-778-4295
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45291207Y00000X, 207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD74453Medicare UPIN