Provider Demographics
NPI:1962499624
Name:CARRICO, MATHEIS W (MD)
Entity Type:Individual
Prefix:
First Name:MATHEIS
Middle Name:W
Last Name:CARRICO
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 1:3346 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-685-1066
Mailing Address - Fax:270-685-0881
Practice Address - Street 1:3346 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-685-1066
Practice Address - Fax:270-685-0881
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64098486Medicaid
KY369694OtherBLUE CROSS
IN20524260Medicaid
KY50007250OtherPASS PORT
KY369694OtherBLUE CROSS
IN20524260Medicaid