Provider Demographics
NPI:1841404233
Name:JOHN, JIM MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:MATHEW
Last Name:JOHN
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 1:665 DULUTH HWY STE 801
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8709
Mailing Address - Country:US
Mailing Address - Phone:470-325-0148
Mailing Address - Fax:770-339-0485
Practice Address - Street 1:755 WALTHER RD # 325-0159
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-962-4895
Practice Address - Fax:678-377-3816
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27363207RC0000X
GA64572207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA206429613AMedicaid
GA206429613AMedicaid