Provider Demographics
NPI:1700170867
Name:MATHEW, BIJU BENNY (MD)
Entity Type:Individual
Prefix:
First Name:BIJU
Middle Name:BENNY
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 1:5605 FM 423, STE 500- 355
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-8960
Mailing Address - Country:US
Mailing Address - Phone:817-731-6121
Mailing Address - Fax:
Practice Address - Street 1:6913 CAMP BOWIE BLVD STE 171
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7165
Practice Address - Country:US
Practice Address - Phone:817-731-6121
Practice Address - Fax:817-732-8015
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS7496207RH0002X, 207R00000X
AZ49383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ951062Medicaid
AZZ186805Medicare PIN