Provider Demographics
NPI:1730185927
Name:MATHIS, TIMOTHY E (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8383 MILLICENT WAY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-5207
Mailing Address - Country:US
Mailing Address - Phone:318-797-6661
Mailing Address - Fax:318-795-8512
Practice Address - Street 1:8383 MILLICENT WAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5207
Practice Address - Country:US
Practice Address - Phone:318-797-6661
Practice Address - Fax:318-795-8512
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2024-05-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA07536R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2712976009OtherCIGNA
LA1376884Medicaid
LA5843480OtherAETNA
080039492OtherRR MEDICARE
LAB005OtherTRICARE
LA$$$$$$$$$0OtherBC OF LA
080039492OtherRR MEDICARE
LAB005OtherTRICARE
LA1376884Medicaid