Provider Demographics
NPI:1063511004
Name:MATHEW, MANAPURATHU (MD)
Entity Type:Individual
Prefix:
First Name:MANAPURATHU
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 W SALT CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-1069
Mailing Address - Country:US
Mailing Address - Phone:847-385-7322
Mailing Address - Fax:847-483-7043
Practice Address - Street 1:40 N AIRLITE ST
Practice Address - Street 2:SUITE 4
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4965
Practice Address - Country:US
Practice Address - Phone:847-695-8454
Practice Address - Fax:847-695-9868
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-44623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C39409Medicare UPIN