Provider Demographics
NPI:1184869125
Name:MATHEW, NIBY (MD)
Entity type:Individual
Prefix:DR
First Name:NIBY
Middle Name:
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 1:350 N WALL ST STE 1605
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2901
Mailing Address - Country:US
Mailing Address - Phone:312-201-1234
Mailing Address - Fax:
Practice Address - Street 1:23120 S LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-7760
Practice Address - Country:US
Practice Address - Phone:815-464-5440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-051772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine