Provider Demographics
NPI:1043381809
Name:MATHEWSON, JAMES WALLACE (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WALLACE
Last Name:MATHEWSON
Suffix:
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 1:6404 E SETTLERS RUN RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7216
Mailing Address - Country:US
Mailing Address - Phone:858-395-8652
Mailing Address - Fax:
Practice Address - Street 1:1330 N RIM DR
Practice Address - Street 2:SUITE A
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3134
Practice Address - Country:US
Practice Address - Phone:928-779-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29338208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293380Medicaid
CAA44018Medicare UPIN
CAWG29338AMedicare ID - Type Unspecified