Provider Demographics
NPI:1063453074
Name:MATHEW, SOBHAN A (MD)
Entity Type:Individual
Prefix:
First Name:SOBHAN
Middle Name:A
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-0157
Mailing Address - Country:US
Mailing Address - Phone:301-570-4280
Mailing Address - Fax:301-260-2838
Practice Address - Street 1:3048 MITCHELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1388
Practice Address - Country:US
Practice Address - Phone:301-218-1456
Practice Address - Fax:301-218-1462
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47604207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD847175400Medicaid
MD490901Medicare PIN
MD847175400Medicaid