Provider Demographics
NPI:1134315823
Name:MATHEWS, MARION J (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:J
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 FEROL LN
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3213
Mailing Address - Country:US
Mailing Address - Phone:850-769-6105
Mailing Address - Fax:
Practice Address - Street 1:114 AIRPORT RD STE C
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4738
Practice Address - Country:US
Practice Address - Phone:850-769-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26212207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03345YOtherMEDICARE PTAN
080008409OtherRAILROAD MEDICARE
FL03345OtherBC/BS FLORIDA
FLME26212OtherMEDICAL LICENSE NO.
080008409OtherRAILROAD MEDICARE