Provider Demographics
NPI:1417912742
Name:MATHEW, TOMS P (MD)
Entity Type:Individual
Prefix:
First Name:TOMS
Middle Name:P
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 1:19270 HANNAN RD
Mailing Address - Street 2:PO BOX 725
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9811
Mailing Address - Country:US
Mailing Address - Phone:734-753-4350
Mailing Address - Fax:
Practice Address - Street 1:19270 HANNAN RD
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:MI
Practice Address - Zip Code:48164-9811
Practice Address - Country:US
Practice Address - Phone:734-753-4350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108287352OtherBCBS
MI4095933Medicaid
F81499Medicare UPIN
MI1108287352OtherBCBS