Provider Demographics
NPI:1922070614
Name:MATHEW, SURESH (MD)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 DUNN RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-6132
Mailing Address - Country:US
Mailing Address - Phone:314-355-1166
Mailing Address - Fax:314-355-9179
Practice Address - Street 1:11125 DUNN RD
Practice Address - Street 2:SUITE 304
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6132
Practice Address - Country:US
Practice Address - Phone:314-355-1166
Practice Address - Fax:314-355-9179
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002016480207RN0300X
MO20022016480207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002016480Medicaid
MO205931108Medicaid
MO000095524Medicare PIN
G57913Medicare UPIN
MO916501798Medicare ID - Type Unspecified