Provider Demographics
NPI:1528259710
Name:MATHERNE, RYAN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOSEPH
Last Name:MATHERNE
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 1:951 HIGHWAY 654
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:LA
Mailing Address - Zip Code:70375-2025
Mailing Address - Country:US
Mailing Address - Phone:504-450-9966
Mailing Address - Fax:
Practice Address - Street 1:416 HIGHWAY 308
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-5752
Practice Address - Country:US
Practice Address - Phone:985-446-5888
Practice Address - Fax:985-446-5880
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3169207N00000X, 207ND0900X
LAMD.202680207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C904OtherMEDICARE GROUP PIN
LA1500615Medicaid