Provider Demographics
NPI:1427043579
Name:MATHESON, BRETT K (MD, FACMS)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:K
Last Name:MATHESON
Suffix:
Gender:M
Credentials:MD, FACMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 RESEARCH PKWY STE 165
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1026
Mailing Address - Country:US
Mailing Address - Phone:719-574-0310
Mailing Address - Fax:719-593-5947
Practice Address - Street 1:1975 RESEARCH PKWY STE 165
Practice Address - Street 2:
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1026
Practice Address - Country:US
Practice Address - Phone:719-574-0310
Practice Address - Fax:719-574-6574
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35631207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01356310Medicaid
CO372018Medicare PIN
CO01356310Medicaid