Provider Demographics
NPI:1578874863
Name:MATHIE, MORGAN FULLMER (DO)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:FULLMER
Last Name:MATHIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 41150
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85274-1150
Mailing Address - Country:US
Mailing Address - Phone:480-425-2162
Mailing Address - Fax:
Practice Address - Street 1:2421 E SOUTHERN AVE
Practice Address - Street 2:STE 7
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7612
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-262-8890
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006380207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ170223Medicare PIN