Healthcare Provider Details

I. General information

NPI: 1326042029
Provider Name (Legal Business Name): CHARLES A MATHIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE STE 400
ELKHART IN
46514-2477
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-2284
  • Fax: 574-522-3952
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01041130A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: