Provider Demographics
NPI:1508813924
Name:MATHEW, SHIRLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:
Last Name:MATHEW
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 1:1000 NORTHERN BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5312
Mailing Address - Country:US
Mailing Address - Phone:516-829-8777
Mailing Address - Fax:519-829-7926
Practice Address - Street 1:104 N RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-3438
Practice Address - Country:US
Practice Address - Phone:516-829-8777
Practice Address - Fax:516-829-7926
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01647694Medicaid
NY2Z5611OtherBLUE CROSS
NY2516647OtherGHI
NY760831Medicare ID - Type Unspecified
NY2Z5611OtherBLUE CROSS