Basic Information
| Provider Information | |||||||||
| NPI: | 1154534477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHYS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BELMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280123368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953700 | ||||||||
| FaxNumber: | 7042953707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 060667 | GA | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 2009-00712 | NC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 153UN | 01 | NC | BCBSNC | OTHER | 929929330A | 05 | GA | MEDICAID | 1444706 | 01 | SC | WELLCARE OF SC | OTHER | NCY847A | 01 | NC | NC MEDICARE | OTHER | 1645113 | 01 | NC | CIGNA | OTHER | NC3156 | 05 | SC | MEDICAID |