Provider Demographics
NPI:1447354709
Name:MATHEW, MATHEW C (MD)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:C
Last Name:MATHEW
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 1:215 E. 1ST STREET, SUITE #212
Mailing Address - Street 2:KSB MEDICAL GROUP
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-285-5484
Mailing Address - Fax:815-285-5486
Practice Address - Street 1:215 E. 1ST STREET, SUITE #212
Practice Address - Street 2:KSB MEDICAL GROUP
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5484
Practice Address - Fax:815-285-5486
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056556208800000X
IL036.056556208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056556Medicaid
IL036056556Medicaid
684960Medicare ID - Type Unspecified