Provider Demographics
NPI:1376531970
Name:MATHUR, RENEE JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:JENNIFER
Last Name:MATHUR
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 1:913 MENOHER BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2834
Mailing Address - Country:US
Mailing Address - Phone:814-288-2669
Mailing Address - Fax:814-288-2667
Practice Address - Street 1:913 MENOHER BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2834
Practice Address - Country:US
Practice Address - Phone:814-288-2669
Practice Address - Fax:814-288-2667
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-09
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064636L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017037110008Medicaid
PA168754Medicare PIN
PAG76394Medicare UPIN