Provider Demographics
NPI:1518311299
Name:MATHEW, LEEDA MERIN (DO)
Entity Type:Individual
Prefix:MS
First Name:LEEDA
Middle Name:MERIN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11474 JACOBSEN RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-6241
Mailing Address - Country:US
Mailing Address - Phone:503-593-1160
Mailing Address - Fax:
Practice Address - Street 1:200 MULLINS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3983
Practice Address - Country:US
Practice Address - Phone:541-259-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty