Healthcare Provider Details

I. General information

NPI: 1295856557
Provider Name (Legal Business Name): GOSSIE COLETTE HEATH MATHIS M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GOSSIE MATHIS

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PLAZA CIR
SANTEE SC
29142-9630
US

IV. Provider business mailing address

PO BOX 277
SANTEE SC
29142-0277
US

V. Phone/Fax

Practice location:
  • Phone: 803-854-3940
  • Fax: 803-854-3945
Mailing address:
  • Phone: 803-854-3940
  • Fax: 803-854-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number13454
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: