Provider Demographics
NPI:1194855734
Name:MATHWICH, BRIAN NEAL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:NEAL
Last Name:MATHWICH
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2055 S PACHECO ST STE 600
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3995
Mailing Address - Country:US
Mailing Address - Phone:505-930-5065
Mailing Address - Fax:888-571-1203
Practice Address - Street 1:2055 S PACHECO ST STE 600
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3995
Practice Address - Country:US
Practice Address - Phone:505-930-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0034519207QG0300X, 207Q00000X
NMMD2020-0324207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF7783-9Medicare UPIN