Provider Demographics
NPI:1790766806
Name:MATHIS, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MATHIS
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:QUALITY SERVICES / 7TH FLOOR ATTN: MCHE-ZQQ
Mailing Address - City:FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-4218
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR APT 7
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-4218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010518572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790766806OtherUS ARMY