Provider Demographics
NPI:1093005993
Name:MATHIS, HENRIETTE MERCEDES (MD)
Entity Type:Individual
Prefix:MISS
First Name:HENRIETTE
Middle Name:MERCEDES
Last Name:MATHIS
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:P.O. BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-9741
Mailing Address - Fax:214-648-9531
Practice Address - Street 1:1615 OSPREY DR STE 107
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2427
Practice Address - Country:US
Practice Address - Phone:469-930-5842
Practice Address - Fax:866-315-5210
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP9647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program