Provider Demographics
NPI:1265819569
Name:MATHEW, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
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 1:121 DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5425
Mailing Address - Country:US
Mailing Address - Phone:718-250-6277
Mailing Address - Fax:
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-250-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10237800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program