Provider Demographics
NPI:1295199073
Name:MATHEW, MATT (MD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:
Last Name:MATHEW
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 1:4181 HOSPITAL DR NE STE 204
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2541
Mailing Address - Country:US
Mailing Address - Phone:678-766-8999
Mailing Address - Fax:
Practice Address - Street 1:4181 HOSPITAL DR NE STE 204
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2541
Practice Address - Country:US
Practice Address - Phone:678-766-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-07
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036154764207X00000X
GA92094207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty