Provider Demographics
NPI:1558365106
Name:MATHESON, THOMAS BLAIR (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BLAIR
Last Name:MATHESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58623-4518
Mailing Address - Country:US
Mailing Address - Phone:701-523-3226
Mailing Address - Fax:701-523-7107
Practice Address - Street 1:12 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:ND
Practice Address - Zip Code:58623-4518
Practice Address - Country:US
Practice Address - Phone:701-523-3226
Practice Address - Fax:701-523-7107
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND7998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10597Medicaid
ND10597Medicaid
F33987Medicare UPIN