Provider Demographics
NPI:1467572107
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 1:5151 E BROADWAY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1346
Mailing Address - Country:US
Mailing Address - Phone:480-290-7000
Mailing Address - Fax:602-254-6840
Practice Address - Street 1:3811 E BELL RD STE 107
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2158
Practice Address - Country:US
Practice Address - Phone:602-340-1689
Practice Address - Fax:602-340-1853
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33087207RP1001X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ33087OtherAZ MD LIC
AZ874554OtherUPIN
AZ874554Medicaid