Provider Demographics
NPI:1316926421
Name:MATHEWS, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MATHEWS
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 1:18643 AVENUE CAPRI
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5346
Mailing Address - Country:US
Mailing Address - Phone:813-948-6696
Mailing Address - Fax:
Practice Address - Street 1:14533 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6065
Practice Address - Country:US
Practice Address - Phone:352-597-2008
Practice Address - Fax:352-597-2070
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79158174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL421557400OtherTAX ID
FLME79158OtherFLORIDA STATE MEDICAL LIC
FL258295300Medicaid