Provider Demographics
NPI:1932660628
Name:MATHEWS, ELIZABETH V (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:V
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:J
Other - Last Name:VILLAFUERTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4880 CENTURY PLAZA RD STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5471
Practice Address - Country:US
Practice Address - Phone:317-216-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02006795A208000000X
IL125.073992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430E99OtherMEDICARE PTAN
IN300063148Medicaid