Provider Demographics
NPI:1568606408
Name:MATHAI, KOSHY MATHEWS (MD)
Entity Type:Individual
Prefix:DR
First Name:KOSHY
Middle Name:MATHEWS
Last Name:MATHAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 MEDICAL PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-8421
Mailing Address - Country:US
Mailing Address - Phone:681-342-3500
Mailing Address - Fax:
Practice Address - Street 1:227 MEDICAL PARK DR STE 103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-8421
Practice Address - Country:US
Practice Address - Phone:681-342-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25084207LP2900X
PAMD-439805207L00000X
PAMT188551207L00000X
LAMD 204524207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology