Provider Demographics
NPI:1497839187
Name:MATHIASON, DELRAY JAMES (DC)
Entity Type:Individual
Prefix:
First Name:DELRAY
Middle Name:JAMES
Last Name:MATHIASON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-1118
Mailing Address - Country:US
Mailing Address - Phone:320-732-3317
Mailing Address - Fax:320-732-3374
Practice Address - Street 1:18 2ND ST N
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347-1118
Practice Address - Country:US
Practice Address - Phone:320-732-3317
Practice Address - Fax:320-732-3374
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU60378Medicare UPIN