Provider Demographics
NPI:1952378747
Name:MATHEWS, MALCOLM III (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:
Last Name:MATHEWS
Suffix:III
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 1:2205 PAVILION DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-6466
Mailing Address - Fax:423-857-6456
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 101
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-6466
Practice Address - Fax:423-857-6456
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16245207RX0202X
VA0101232053207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ011077Medicaid
VA1952378747Medicaid
VA005847966Medicaid
TN3026910Medicaid
TN830007078Medicare PIN
VA005847966Medicaid
TN3026910Medicare PIN
A99082Medicare UPIN
VA005797W85Medicare PIN
TN103I901648Medicare PIN