Provider Demographics
NPI:1417912411
Name:AGUSTSSON MATHERS, ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:
Last Name:AGUSTSSON MATHERS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:T
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5870
Mailing Address - Fax:815-395-5750
Practice Address - Street 1:1601 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1822
Practice Address - Country:US
Practice Address - Phone:815-395-5870
Practice Address - Fax:815-395-5750
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036039266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036039266OtherSTATE MEDICAL LICENSE
IL036039266OtherSTATE MEDICAL LICENSE
IL036039266OtherSTATE MEDICAL LICENSE
IL336008741OtherILLINOIS DEA