Provider Demographics
NPI:1720033392
Name:MATHEW, KALLUKALAM JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:KALLUKALAM
Middle Name:JOSEPH
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6504 KENILWORTH AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1386
Mailing Address - Country:US
Mailing Address - Phone:301-927-8011
Mailing Address - Fax:301-699-1584
Practice Address - Street 1:6504 KENILWORTH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1386
Practice Address - Country:US
Practice Address - Phone:301-927-8011
Practice Address - Fax:301-699-1584
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014799207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD060042761Medicaid
MD173171R96Medicare ID - Type Unspecified
MDD09455Medicare UPIN