Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Y00000X | Otolaryngologist (ENT Doctor) | 079724 | GA |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 30998 | AZ |
NPI | 1043341043 |
---|---|
Provider Name | Shawn Bell Mathews |
First Address | Lagrange, GA 30240-4130 |
Second Address | Lagrange, GA 30240-4130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2007 |
Last Update Date | 02/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
755879 | (05) | AZ |
AZ0728210 | BLUE CROSS BLUE SHIELD (01) | AZ |
H34704 | (02) | AZ |