Provider Demographics
NPI:1831141670
Name:MATHEW, PUTHENPURAKAL K (MD)
Entity Type:Individual
Prefix:
First Name:PUTHENPURAKAL
Middle Name:K
Last Name:MATHEW
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 1:1561 LONG POND ROAD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626
Mailing Address - Country:US
Mailing Address - Phone:585-723-7872
Mailing Address - Fax:585-723-7236
Practice Address - Street 1:1561 LONG POND ROAD
Practice Address - Street 2:SUITE 401
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626
Practice Address - Country:US
Practice Address - Phone:585-723-7872
Practice Address - Fax:585-723-7236
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113601207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00458315Medicaid
1136019WCIMCDOtherWORKER'S COMPENSATION
NYRA0333Medicare ID - Type UnspecifiedBA0017 GROUP
1136019WCIMCDOtherWORKER'S COMPENSATION
NYDD3074Medicare ID - Type Unspecified70008A GROUP