Provider Demographics
NPI:1346535838
Name:MATHEW, MANOJ (MD)
Entity Type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:MATHEW
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:AS 100,PSC BOX 21034
Mailing Address - Street 2:MAG 29 MCAS NEW RIVER NC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-1034
Mailing Address - Country:US
Mailing Address - Phone:910-449-6500
Mailing Address - Fax:
Practice Address - Street 1:AS100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28542-1034
Practice Address - Country:US
Practice Address - Phone:910-449-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI59999-20171000000X, 2083P0500X, 261QP2300X, 2083A0100X
WI5999-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace MedicineGroup - Multi-Specialty
No171000000XOther Service ProvidersMilitary Health Care Provider
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care