Provider Demographics
NPI:1083611628
Name:JOHN, ELCY MATHAI (MD)
Entity Type:Individual
Prefix:MS
First Name:ELCY
Middle Name:MATHAI
Last Name:JOHN
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 1:455 SCHOOL ST
Mailing Address - Street 2:SUITE 29
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4595
Mailing Address - Country:US
Mailing Address - Phone:281-374-1860
Mailing Address - Fax:281-255-0550
Practice Address - Street 1:455 SCHOOL ST
Practice Address - Street 2:SUITE 29
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4595
Practice Address - Country:US
Practice Address - Phone:281-374-1860
Practice Address - Fax:281-255-0550
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8126174400000X, 207V00000X
OK24991207V00000X
OK34806207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200099770AMedicaid
TX8R1193OtherBLUE CROSS BLUE SHIELD
TX171664901Medicaid
TX8R1193OtherBLUE CROSS BLUE SHIELD
126602Medicare UPIN
TXI26602Medicare UPIN
TX8D3989Medicare ID - Type Unspecified