Provider Demographics
NPI:1821213331
Name:MATHIS, MARJORIE JANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:JANE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:JANIE
Other - Middle Name:
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-408-6220
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-408-6220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001950207R00000X, 208M00000X
UT9104460-1204208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8445835Medicaid
WAG8858565Medicare PIN
WAG8858563Medicare PIN
WAG8872455Medicare PIN
WAG8858567Medicare PIN
WAG8858566Medicare PIN
WAG8858564Medicare PIN
WA8445835Medicaid