Provider Demographics
NPI:1063506343
Name:MATHURA, JEEVAN (MD)
Entity Type:Individual
Prefix:
First Name:JEEVAN
Middle Name:
Last Name:MATHURA
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 1:1108 16TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-4802
Mailing Address - Country:US
Mailing Address - Phone:202-347-8500
Mailing Address - Fax:202-783-1007
Practice Address - Street 1:1344 MARYLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4402
Practice Address - Country:US
Practice Address - Phone:202-399-1616
Practice Address - Fax:202-000-0000
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD25651207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C62124Medicare ID - Type Unspecified