Provider Demographics
NPI:1730255233
Name:MATHIS, WAYNE DOUGLASS (DC)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:DOUGLASS
Last Name:MATHIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10832 CROCKETT ST.
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352
Mailing Address - Country:US
Mailing Address - Phone:818-768-4502
Mailing Address - Fax:
Practice Address - Street 1:3609 W. MAGNOLIA BLVD.
Practice Address - Street 2:
Practice Address - City:BURBANK,
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-845-5895
Practice Address - Fax:818-954-8634
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15307111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC15307OtherSTATE LICENSE NUMBER