Provider Demographics
NPI:1992068894
Name:MATHEW, JACOB JR (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:MATHEW
Suffix:JR
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 1:1650 COCHRANE CIR
Mailing Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:EVANS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4613
Practice Address - Country:US
Practice Address - Phone:719-526-6073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
HIDOS-1566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000OtherUPIN