Provider Demographics
NPI:1912940487
Name:MATHIS, KENNETH B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6400 FANNIN ST STE 1700
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1526
Mailing Address - Country:US
Mailing Address - Phone:713-486-5555
Mailing Address - Fax:713-486-7533
Practice Address - Street 1:6400 FANNIN ST STE 1700
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1526
Practice Address - Country:US
Practice Address - Phone:713-486-5555
Practice Address - Fax:713-486-7533
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0610207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S9717OtherBCBS
TXE35566Medicare UPIN
TX8E0655Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE