Provider Demographics
NPI:1770711871
Name:MATHEW, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 SHARPSBURG MCCULLUM RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2297
Mailing Address - Country:US
Mailing Address - Phone:678-633-3260
Mailing Address - Fax:
Practice Address - Street 1:2959 SHARPSBURG MCCULLUM RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2297
Practice Address - Country:US
Practice Address - Phone:678-633-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100044207Q00000X
GA076067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770711871Medicaid