Provider Demographics
NPI:1619720331
Name:MATTATHIL, SHELBIN JACOB (MS)
Entity Type:Individual
Prefix:
First Name:SHELBIN
Middle Name:JACOB
Last Name:MATTATHIL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 WEDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:LUCAS
Mailing Address - State:TX
Mailing Address - Zip Code:75002-7480
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:925 CITY CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2981
Practice Address - Country:US
Practice Address - Phone:936-202-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program