Provider Demographics
NPI:1346232097
Name:KANDATHIL, MATHEW K (MD)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:K
Last Name:KANDATHIL
Suffix:
Gender:M
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:PO BOX 100707
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0707
Mailing Address - Country:US
Mailing Address - Phone:305-434-3400
Mailing Address - Fax:
Practice Address - Street 1:91550 OVERSEAS HWY STE 205
Practice Address - Street 2:
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2513
Practice Address - Country:US
Practice Address - Phone:305-434-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40740207R00000X
FLME139797207RG0100X
MA40612207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3533409Medicaid
NJ171958ALKMedicare ID - Type Unspecified
C53707Medicare UPIN
NJ3533409Medicaid