1750085148 NPI number — MARY NEONTA MATHISON MD

Table of content: MARY NEONTA MATHISON MD (NPI 1750085148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750085148 NPI number — MARY NEONTA MATHISON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHISON
Provider First Name:
MARY
Provider Middle Name:
NEONTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATHISON
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
HARDIN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750085148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8783 GREENSBOROUGH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLANDS RANCH
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80129-1546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-852-0918
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 UNIVERSITY OF NEW MEXICO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87131-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-272-8244
Provider Business Practice Location Address Fax Number:
505-272-4639
Provider Enumeration Date:
03/29/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)