Provider Demographics
NPI:1114371176
Name:MATHEW, MERIN ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:MERIN
Middle Name:ELIZABETH
Last Name:MATHEW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CENTRAL ST APT 1N
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1469
Mailing Address - Country:US
Mailing Address - Phone:716-406-8186
Mailing Address - Fax:
Practice Address - Street 1:2323 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-270-4932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068929207R00000X
WI70723207R00000X
IL036166722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine