Provider Demographics
NPI:1427119122
Name:MATTISON, EDWARD C (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:MATTISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 CORNELIA RD
Mailing Address - Street 2:PO BOX 1847
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3317
Mailing Address - Country:US
Mailing Address - Phone:864-224-0028
Mailing Address - Fax:864-225-5067
Practice Address - Street 1:1116 CORNELIA RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3317
Practice Address - Country:US
Practice Address - Phone:864-224-0028
Practice Address - Fax:864-225-5067
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC04955207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC049557Medicaid
SC049557Medicaid