Provider Demographics
NPI:1982265310
Name:MATHEWS, CARL DUANE JR
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:DUANE
Last Name:MATHEWS
Suffix:JR
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 1:1507 LOVERS LN NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2016
Mailing Address - Country:US
Mailing Address - Phone:330-980-1007
Mailing Address - Fax:
Practice Address - Street 1:318 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-4605
Practice Address - Country:US
Practice Address - Phone:330-395-9563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000503722OtherANTHEM