1750432688 NPI number — DR. JONATHAN RICHARD MATTHEWS D.O.

Table of content: DR. JONATHAN RICHARD MATTHEWS D.O. (NPI 1750432688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750432688 NPI number — DR. JONATHAN RICHARD MATTHEWS D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTHEWS
Provider First Name:
JONATHAN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTHEWS
Provider Other First Name:
JONATHAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1750432688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 TROPHY CLUB DR
Provider Second Line Business Mailing Address:
STE 600
Provider Business Mailing Address City Name:
TROPHY CLUB
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-490-9841
Provider Business Mailing Address Fax Number:
817-490-9841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 TROPHY CLUB DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
TROPHY CLUB
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76262-5415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-490-9841
Provider Business Practice Location Address Fax Number:
817-490-9838
Provider Enumeration Date:
01/16/2007

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: 207R00000X , with the licence number:  L9803 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8X2575 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 188312601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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