Provider Demographics
NPI:1073536017
Name:MATTHEWS, JACQUIN P (MD)
Entity Type:Individual
Prefix:
First Name:JACQUIN
Middle Name:P
Last Name:MATTHEWS
Suffix:
Gender:F
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-870-1818
Practice Address - Street 1:851 W TERRELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3161
Practice Address - Country:US
Practice Address - Phone:817-870-1551
Practice Address - Fax:817-870-1818
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4909207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034648803Medicaid
P00007979OtherRAILROAD MEDICARE
P00007979OtherRAILROAD MEDICARE
TX8A6267Medicare PIN