Provider Demographics
NPI:1427462985
Name:MATHES, KELLY A (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MATHES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:333 N GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1954
Mailing Address - Country:US
Mailing Address - Phone:920-729-6088
Mailing Address - Fax:920-729-6484
Practice Address - Street 1:333 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1954
Practice Address - Country:US
Practice Address - Phone:920-729-6088
Practice Address - Fax:920-729-6484
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67780-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100070814Medicaid
1044793358OtherAMERICAN BOARD OF FAMILY MEDICINE