Provider Demographics
NPI:1114950565
Name:MATHEW, TITTYMOL (MD)
Entity Type:Individual
Prefix:
First Name:TITTYMOL
Middle Name:
Last Name:MATHEW
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 1:9 CROWN CT
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-4440
Mailing Address - Country:US
Mailing Address - Phone:732-922-3278
Mailing Address - Fax:732-341-8901
Practice Address - Street 1:530 LAKEHURST RD
Practice Address - Street 2:SUITE 307
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8063
Practice Address - Country:US
Practice Address - Phone:732-341-8901
Practice Address - Fax:732-341-8906
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2011-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA71468207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH49067Medicare UPIN
NJ051348Medicare PIN