Provider Demographics
NPI:1417310764
Name:MATHEW, JUSTIN ITTY (MD, MLS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ITTY
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD, MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSC10 5550 1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4661
Mailing Address - Fax:505-272-0475
Practice Address - Street 1:MSC10 5550 1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-4661
Practice Address - Fax:505-272-0475
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2018-0609390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty