Provider Demographics
NPI:1538112339
Name:MATHIESON, BRETT L (MD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:L
Last Name:MATHIESON
Suffix:
Gender:M
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:726 4TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5656
Practice Address - Country:US
Practice Address - Phone:530-749-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76823207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G768230Medicaid
CACA230339Medicare PIN
CA00G768230Medicaid
CABF223ZMedicare PIN
CA00G768231Medicare PIN
CACA165882Medicare PIN
CA050087885Medicare PIN
G07347Medicare UPIN
CABF233YMedicare PIN