Provider Demographics
NPI:1104854363
Name:MATHAI, MATHEW GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:GEORGE
Last Name:MATHAI
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 1:5900 S. LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110
Mailing Address - Country:US
Mailing Address - Phone:414-744-4000
Mailing Address - Fax:414-489-4022
Practice Address - Street 1:5900 S. LAKE DR.
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110
Practice Address - Country:US
Practice Address - Phone:414-744-4000
Practice Address - Fax:414-489-4022
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45983207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34650600Medicaid
WI34650600Medicaid