Provider Demographics
NPI:1093015299
Name:MATHURA, VIDYA LYSTRA
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:LYSTRA
Last Name:MATHURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 KING ST
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1069
Mailing Address - Country:US
Mailing Address - Phone:914-937-3800
Mailing Address - Fax:
Practice Address - Street 1:4125 CARPENTER AVENUE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1069
Practice Address - Country:US
Practice Address - Phone:718-655-0261
Practice Address - Fax:718-654-7930
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018126-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics