Provider Demographics
NPI:1790788867
Name:MATHIS, TIMOTHY A (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
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 1:8636 STANDISH RD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-1441
Mailing Address - Country:US
Mailing Address - Phone:315-339-3302
Mailing Address - Fax:
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1068
Practice Address - Country:US
Practice Address - Phone:315-624-6068
Practice Address - Fax:315-624-6308
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173917207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E16885Medicare UPIN