Provider Demographics
NPI:1659612927
Name:MATHIS, MICHAEL OTHELLO JR (SURFACE FORCE IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OTHELLO
Last Name:MATHIS
Suffix:JR
Gender:M
Credentials:SURFACE FORCE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS TRUXTUN
Mailing Address - Street 2:DDG 103
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09588-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS TRUXTUN
Practice Address - Street 2:DDG 103
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09588-1309
Practice Address - Country:US
Practice Address - Phone:757-445-6164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2865X1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2865X1600XHospitalsMilitary HospitalMilitary General Acute Care Hospital. Operational (Transportable)