Provider Demographics
NPI:1235549650
Name:MATHEW, RENJAN ROY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RENJAN
Middle Name:ROY
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 SANTA ANITA BLVD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-4887
Mailing Address - Country:US
Mailing Address - Phone:469-585-5393
Mailing Address - Fax:
Practice Address - Street 1:600 E JOHN CARPENTER FWY
Practice Address - Street 2:STE 291
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062
Practice Address - Country:US
Practice Address - Phone:469-444-3226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36436103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist