Provider Demographics
NPI:1447367859
Name:MATHIS, NANCY J (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:MATHIS
Suffix:
Gender:F
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:PO BOX 2626
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2626
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-226-8884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7182207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0004MPOtherBCBS
TX174681001Medicaid
TX174681001Medicaid
TXP00231658Medicare PIN