Provider Demographics
NPI:1649450586
Name:MATHIAS, BRAD T
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:T
Last Name:MATHIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2674
Mailing Address - Country:US
Mailing Address - Phone:478-452-4800
Mailing Address - Fax:
Practice Address - Street 1:850 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2674
Practice Address - Country:US
Practice Address - Phone:478-452-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46786207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00813799AMedicaid
GAD54137Medicare UPIN
GA00813799AMedicaid