Provider Demographics
NPI:1467961797
Name:MATHEWS, MALIK ELIJAH
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:ELIJAH
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 ADAMS DR APT 8A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-2624
Mailing Address - Country:US
Mailing Address - Phone:757-902-0933
Mailing Address - Fax:
Practice Address - Street 1:761 ADAMS DR APT 8A
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2624
Practice Address - Country:US
Practice Address - Phone:757-902-0933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT68108668344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA822455857Medicaid