Provider Demographics
NPI:1558519405
Name:MATHEW, THRESIAMMA (MD)
Entity Type:Individual
Prefix:
First Name:THRESIAMMA
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 1:2430 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-5930
Mailing Address - Country:US
Mailing Address - Phone:718-646-0772
Mailing Address - Fax:
Practice Address - Street 1:2623 E 16TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3805
Practice Address - Country:US
Practice Address - Phone:718-934-2424
Practice Address - Fax:718-934-2477
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247349208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation