Basic Information
| Provider Information | |||||||||
| NPI: | 1609952217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | EDWIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4947 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312084947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783012362 | ||||||||
| FaxNumber: | 4783012272 | ||||||||
| Practice Location | |||||||||
| Address1: | 707 PINE STREET | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783015801 | ||||||||
| FaxNumber: | 4783015812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 07/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 035103 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000482853E | 05 | GA | MEDICAID | 110183236 | 01 | GA | RAILROAD MEDICARE | OTHER |