Basic Information
| Provider Information | |||||||||
| NPI: | 1750314068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHAN | ||||||||
| FirstName: | SATISH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 SITUS CT | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276064165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198342767 | ||||||||
| FaxNumber: | 9198340234 | ||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843211 | ||||||||
| FaxNumber: | 9197843497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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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 | 2085R0202X | 200200139 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5901623 | 05 | NC | MEDICAID |