Healthcare Provider Details

I. General information

NPI: 1720709397
Provider Name (Legal Business Name): JIMMY L MATHIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 CIVIC CENTER DR
N LAS VEGAS NV
89030-6327
US

IV. Provider business mailing address

2123 CIVIC CENTER DR
N LAS VEGAS NV
89030-6327
US

V. Phone/Fax

Practice location:
  • Phone: 702-772-8063
  • Fax:
Mailing address:
  • Phone: 702-772-8063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number00093077
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: