Provider Demographics
NPI:1508069659
Name:MATHIVANAN, VIDYA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDYA
Middle Name:
Last Name:MATHIVANAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 GALLION DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1967
Mailing Address - Country:US
Mailing Address - Phone:281-812-7404
Mailing Address - Fax:
Practice Address - Street 1:16659 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2375
Practice Address - Country:US
Practice Address - Phone:281-812-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN 3875207R00000X
OH57-011167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine