Healthcare Provider Details

I. General information

NPI: 1063890200
Provider Name (Legal Business Name): JONATHAN MATHIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JACKSON PIKE
GALLIPOLIS OH
45631
US

IV. Provider business mailing address

90 JACKSON PIKE
GALLIPOLIS OH
45631-1562
US

V. Phone/Fax

Practice location:
  • Phone: 855-446-5937
  • Fax: 740-446-5711
Mailing address:
  • Phone: 740-441-1934
  • Fax: 740-446-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL38060
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.133539
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: