Provider Demographics
NPI:1295701365
Name:MATHIESON, ISABEL M (DO)
Entity type:Individual
Prefix:
First Name:ISABEL
Middle Name:M
Last Name:MATHIESON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11928 BOYETTE ROAD
Mailing Address - Street 2:BOYETTE EXECUTIVE CENTER
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5601
Mailing Address - Country:US
Mailing Address - Phone:813-671-5800
Mailing Address - Fax:813-671-9966
Practice Address - Street 1:11928 BOYETTE RD
Practice Address - Street 2:BOYETTE EXECUTIVE CENTER
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-5601
Practice Address - Country:US
Practice Address - Phone:813-671-5800
Practice Address - Fax:813-671-9966
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7215207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255814900Medicaid
FLE0861AMedicare ID - Type UnspecifiedMEDICARE
FLG72590Medicare UPIN