Provider Demographics
NPI:1770310567
Name:MATHEW, MANJU
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:MATHEW
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 1:120 LAKE NANUET DR
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-3516
Mailing Address - Country:US
Mailing Address - Phone:845-538-7946
Mailing Address - Fax:
Practice Address - Street 1:MONTEFIORE MEDICAL CENTER
Practice Address - Street 2:111 E 210 STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-6660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF35338101363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily