Provider Demographics
NPI:1578512141
Name:MATHEW, THOMAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:MATHEW
Suffix:JR
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 1:330 ALCOVY ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2140
Mailing Address - Country:US
Mailing Address - Phone:770-267-1802
Mailing Address - Fax:770-267-1796
Practice Address - Street 1:330 ALCOVY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2140
Practice Address - Country:US
Practice Address - Phone:770-267-1802
Practice Address - Fax:770-267-1796
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051534684Medicaid
AL1578512141OtherNPI
AL051534684Medicaid
AL1578512141OtherNPI