Provider Demographics
NPI:1699763953
Name:MATHESON, CRAIG K (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:K
Last Name:MATHESON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 W US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:SCOTTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49454-9601
Mailing Address - Country:US
Mailing Address - Phone:231-757-2500
Mailing Address - Fax:231-757-9073
Practice Address - Street 1:821 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:SCOTTVILLE
Practice Address - State:MI
Practice Address - Zip Code:49454-9601
Practice Address - Country:US
Practice Address - Phone:231-757-2500
Practice Address - Fax:231-757-9073
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4615194Medicaid
MI0855301234OtherBLUE CROSS BLUE SHIELD ID
MI23D1038209OtherCLIA
MIN96780001Medicare ID - Type UnspecifiedINDIVIDUAL
MI0855301234OtherBLUE CROSS BLUE SHIELD ID