Healthcare Provider Details

I. General information

NPI: 1598752875
Provider Name (Legal Business Name): GARY L. MATHEWS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 CAMELLIA BLVD STE 100
LAFAYETTE LA
70508-6961
US

IV. Provider business mailing address

141 RIDGEWAY DR STE 201
LAFAYETTE LA
70503-3402
US

V. Phone/Fax

Practice location:
  • Phone: 337-504-5000
  • Fax: 337-504-5646
Mailing address:
  • Phone: 337-981-2277
  • Fax: 337-981-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number019449
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: