Provider Demographics
NPI:1790996353
Name:ISABEL MATHIESON DO PA
Entity Type:Organization
Organization Name:ISABEL MATHIESON DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ISABEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MATHIESON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-671-5800
Mailing Address - Street 1:11928 BOYETTE RD
Mailing Address - Street 2:BOYETTE EXECUTIVE CENTER
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5601
Mailing Address - Country:US
Mailing Address - Phone:813-671-5800
Mailing Address - Fax:813-671-9966
Practice Address - Street 1:11928 BOYETTE RD
Practice Address - Street 2:BOYETTE EXECUTIVE CENTER
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5601
Practice Address - Country:US
Practice Address - Phone:813-671-5800
Practice Address - Fax:813-671-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7215174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG72590Medicare UPIN