Healthcare Provider Details

I. General information

NPI: 1841404233
Provider Name (Legal Business Name): JIM MATHEW JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 WALTHER RD # 325-0159
LAWRENCEVILLE GA
30046
US

IV. Provider business mailing address

665 DULUTH HWY STE 801
LAWRENCEVILLE GA
30046-8709
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-4895
  • Fax: 678-377-3816
Mailing address:
  • Phone: 470-325-0148
  • Fax: 770-339-0485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number27363
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number64572
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: