Basic Information
| Provider Information | |||||||||
| NPI: | 1790766806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3551 ROGER BROOKE DR | ||||||||
| Address2: | QUALITY SERVICES / 7TH FLOOR ATTN: MCHE-ZQQ | ||||||||
| City: | FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164218 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 ROGER BROOKE DR APT 7 | ||||||||
| Address2: | |||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109164218 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101051857 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1790766806 | 01 | US ARMY | OTHER |