Provider Demographics
NPI:1740217504
Name:MATHEW, MARY L (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
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 1:1561 LONG POND RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-368-4000
Mailing Address - Fax:585-368-4815
Practice Address - Street 1:1561 LONG POND RD
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4117
Practice Address - Country:US
Practice Address - Phone:585-368-4000
Practice Address - Fax:585-368-4815
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00318888OtherMEDICARE RR
NY01519653Medicaid
NYRA5113/GRPBA0017Medicare PIN
NYP00318888OtherMEDICARE RR