Provider Demographics
NPI:1063400455
Name:MATHEY, MICHAEL D (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:MATHEY
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 1:334 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4608
Mailing Address - Country:US
Mailing Address - Phone:909-793-3994
Mailing Address - Fax:909-793-9374
Practice Address - Street 1:334 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4608
Practice Address - Country:US
Practice Address - Phone:909-793-3994
Practice Address - Fax:909-793-9374
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0234780Medicaid
CADC0234780Medicare ID - Type UnspecifiedID FOR MEDICARE AND