Healthcare Provider Details

I. General information

NPI: 1477646396
Provider Name (Legal Business Name): JAMES K. MATHESON, DO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 LIBERTY AVE
VERMILION OH
44089-1904
US

IV. Provider business mailing address

4560 LIBERTY AVE
VERMILION OH
44089-1904
US

V. Phone/Fax

Practice location:
  • Phone: 440-967-5433
  • Fax:
Mailing address:
  • Phone: 440-967-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number34004252M
License Number StateOH

VIII. Authorized Official

Name: MR. JAMES K MATHESON
Title or Position: OWNER
Credential: DO
Phone: 440-967-5433