Provider Demographics
NPI:1275858839
Name:MATHESON, HEATHER BENNETT (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:BENNETT
Last Name:MATHESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:520 MARY ST STE 520
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1682
Mailing Address - Country:US
Mailing Address - Phone:812-424-8231
Mailing Address - Fax:812-435-8794
Practice Address - Street 1:520 MARY ST STE 520
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1682
Practice Address - Country:US
Practice Address - Phone:812-424-8231
Practice Address - Fax:812-435-8794
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99090610A208C00000X
FLME129307208C00000X
IN01081542A208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021719Medicaid
KY7100581930Medicaid
FLIR482ZOtherMEDICARE
FL018439300Medicaid
GA003181483AMedicaid
IN01081542AOtherIN PROFESSIONAL LICENSING AGENCY
IN99090610AOtherIN TEMPORARY LICENSE