Provider Demographics
NPI:1831359207
Name:MATHEW, BOBBY (MBBS)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0260
Mailing Address - Fax:716-323-0294
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-0260
Practice Address - Fax:716-323-0294
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0030582080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080801000081OtherFIDELIS
2115250OtherIHA
NY03014486Medicaid
000530534003OtherBC/BS
2115250OtherIHA