Provider Demographics
NPI:1225160351
Name:MATHEW, SUBASH (MD FAAP)
Entity Type:Individual
Prefix:DR
First Name:SUBASH
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 IROQUOIS WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7127
Mailing Address - Country:US
Mailing Address - Phone:510-226-6920
Mailing Address - Fax:510-226-6920
Practice Address - Street 1:611 IROQUOIS WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7127
Practice Address - Country:US
Practice Address - Phone:510-226-6920
Practice Address - Fax:510-226-6920
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50844208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC03047Medicare UPIN