Healthcare Provider Details

I. General information

NPI: 1225142557
Provider Name (Legal Business Name): ROBERT G MATHENY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1739 E BEVERLY AVE SUITE 203
KINGMAN AZ
86409-3593
US

IV. Provider business mailing address

1739 E BEVERLY AVE SUITE 203
KINGMAN AZ
86409-3593
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3133
  • Fax: 928-757-3136
Mailing address:
  • Phone: 928-757-3133
  • Fax: 928-757-3136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number32495
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number32495
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: