Healthcare Provider Details

I. General information

NPI: 1629060900
Provider Name (Legal Business Name): DONALD MILLS MATHESON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 S MAIN ST
WILLITS CA
95490-4305
US

IV. Provider business mailing address

1245 S MAIN ST
WILLITS CA
95490-4305
US

V. Phone/Fax

Practice location:
  • Phone: 707-459-6861
  • Fax: 707-459-3057
Mailing address:
  • Phone: 707-459-6861
  • Fax: 707-459-3057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG25745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: