Provider Demographics
NPI:1497730808
Name:MATHEW, JEAN K (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:K
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE STE 640
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2993
Mailing Address - Country:US
Mailing Address - Phone:503-229-7976
Mailing Address - Fax:503-274-4867
Practice Address - Street 1:9155 SW BARNES RD STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6631
Practice Address - Country:US
Practice Address - Phone:503-292-7704
Practice Address - Fax:503-292-7046
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-20812207RN0300X
ORMD184703207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497730808Medicaid
MI0N20630Medicare PIN
MI1497730808Medicaid