Provider Demographics
NPI:1841242112
Name:MATHEW, MANESH
Entity Type:Individual
Prefix:
First Name:MANESH
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23625 COMMERCE PARK
Mailing Address - Street 2:STE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 OCEAN DR
Practice Address - Street 2:APT W8C
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-1919
Practice Address - Country:US
Practice Address - Phone:917-767-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA114537002085R0202X
FLME1004352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02691972Medicaid
NY932T61OtherBCBS
NY932T61OtherBCBS
NYI09190Medicare UPIN
NY805T01Medicare ID - Type Unspecified
FLAH8352Medicare PIN
NY02691972Medicaid