Provider Demographics
NPI:1710988480
Name:MATHEW, CAROLINE DENNIS (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:DENNIS
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:
Other - Last Name:ZACHARIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4212 LENNON ROAD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1025
Mailing Address - Country:US
Mailing Address - Phone:810-733-2311
Mailing Address - Fax:810-733-8773
Practice Address - Street 1:4212 LENNON ROAD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1025
Practice Address - Country:US
Practice Address - Phone:810-733-2311
Practice Address - Fax:810-733-8773
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P18770Medicaid
MI4381040 10Medicaid
MI4381040Medicaid
MIG29661Medicare UPIN
MI0P18770Medicaid