Provider Demographics
NPI:1619060530
Name:MATHENY, THEODORE RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RAYMOND
Last Name:MATHENY
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 1:617 DAYTON ST STE 2
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3446
Mailing Address - Country:US
Mailing Address - Phone:425-776-3399
Mailing Address - Fax:425-776-5511
Practice Address - Street 1:617 DAYTON ST STE 2
Practice Address - Street 2:#A
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3446
Practice Address - Country:US
Practice Address - Phone:425-776-3399
Practice Address - Fax:425-776-5511
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8289753Medicaid
WA8289753Medicaid