Provider Demographics
NPI:1902856305
Name:MATHEWS, MONTY S (MD)
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:S
Last Name:MATHEWS
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 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-7200
Mailing Address - Fax:402-559-9344
Practice Address - Street 1:988102 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-7200
Practice Address - Fax:402-559-9344
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17230207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE17230OtherNE LICENSE