Provider Demographics
NPI:1912483058
Name:MATHESON, RYAN J (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:J
Last Name:MATHESON
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 1:2240 WINROW RD
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-5080
Mailing Address - Country:US
Mailing Address - Phone:520-533-9033
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW RD
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-5080
Practice Address - Country:US
Practice Address - Phone:301-312-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine