Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | CH5141 | FL |
NPI | 1679571822 |
---|---|
Provider Name | Dr. Darrel Thomas Mathis |
First Address | Lake City, FL 32025-7050 |
Second Address | Lake City, FL 32025-7050 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 04/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
050782200 | (05) | FL |
350023404 | RAILROAD MEDICARE (01) | FL |
T84523 | (02) | FL |