Provider Demographics
NPI:1467080689
Name:MATHIS, CECILIA (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
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:PO BOX 505408
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5408
Mailing Address - Country:US
Mailing Address - Phone:785-448-3131
Mailing Address - Fax:
Practice Address - Street 1:536 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:GARNETT
Practice Address - State:KS
Practice Address - Zip Code:66032-1355
Practice Address - Country:US
Practice Address - Phone:785-448-2674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-48548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program