Provider Demographics
NPI:1912977489
Name:MATHEW, MAMMEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMMEN
Middle Name:M
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 1:243 WOODROW WILSON LANE
Mailing Address - Street 2:PO BOX 1500 BOX W-1
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939
Mailing Address - Country:US
Mailing Address - Phone:540-332-7082
Mailing Address - Fax:
Practice Address - Street 1:243 WOODROW WILSON LANE
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939
Practice Address - Country:US
Practice Address - Phone:540-332-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037344208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006822851Medicaid
VAE44574Medicare UPIN
VA250000047Medicare UPIN
VA006822851Medicaid