Provider Demographics
NPI:1629066980
Name:MATHIEU, JEAN-WILNER (MD)
Entity Type:Individual
Prefix:
First Name:JEAN-WILNER
Middle Name:
Last Name:MATHIEU
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 1:1234 NE 4TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1925
Mailing Address - Country:US
Mailing Address - Phone:954-779-1667
Mailing Address - Fax:954-760-7253
Practice Address - Street 1:1234 NE 4TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-1925
Practice Address - Country:US
Practice Address - Phone:954-779-1667
Practice Address - Fax:954-760-7253
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0042195208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062870100Medicaid
FLA96096Medicare UPIN