Provider Demographics
NPI:1699759019
Name:MATHISEN, DOUGLAS JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:MATHISEN
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Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:671-726-6826
Mailing Address - Fax:617-726-7667
Practice Address - Street 1:55 FRUIT STREET
Practice Address - Street 2:BLK 1570 THORACIC SURGERY DEPARTMENT
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-6826
Practice Address - Fax:617-726-7667
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2012-11-21
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Provider Licenses
StateLicense IDTaxonomies
MA39784208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0182656Medicaid
MA710067OtherTUFTS HEALTH PLAN
MAE05949OtherBCBS MA
B73886Medicare UPIN
MAE05949Medicare ID - Type Unspecified