Provider Demographics
NPI:1295856557
Name:HEATH MATHIS, GOSSIE COLETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:GOSSIE
Middle Name:COLETTE
Last Name:HEATH MATHIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GOSSIE
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:SC
Mailing Address - Zip Code:29142-0277
Mailing Address - Country:US
Mailing Address - Phone:803-854-3940
Mailing Address - Fax:803-854-3945
Practice Address - Street 1:130 PLAZA CIR
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:SC
Practice Address - Zip Code:29142-9630
Practice Address - Country:US
Practice Address - Phone:803-854-3940
Practice Address - Fax:803-854-3945
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13454207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPO261Medicaid
SCD17937Medicare UPIN
SCGPO261Medicaid