Provider Demographics
NPI:1497137228
Name:MATHEW, MANJU (OD)
Entity Type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 TAMARACK LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2012
Mailing Address - Country:US
Mailing Address - Phone:845-641-3464
Mailing Address - Fax:
Practice Address - Street 1:936 2ND STREET PIKE
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1527
Practice Address - Country:US
Practice Address - Phone:215-485-5384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00669000152W00000X
NY008310152W00000X
PAOEG003239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist