Provider Demographics
NPI:1255642641
Name:MATHEWS, RENU
Entity type:Individual
Prefix:
First Name:RENU
Middle Name:
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 W ROBINHOOD DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 W ROBINHOOD DR
Practice Address - Street 2:SUITE G
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5507
Practice Address - Country:US
Practice Address - Phone:209-472-1470
Practice Address - Fax:209-472-1961
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics