Provider Demographics
NPI:1952404105
Name:MATHAI, STEPHEN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THOMAS
Last Name:MATHAI
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 1:1780 VALLEYBROOK PL
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE FINANCE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-5151
Mailing Address - Country:US
Mailing Address - Phone:937-433-2932
Mailing Address - Fax:937-252-1242
Practice Address - Street 1:25 THORPE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1823
Practice Address - Country:US
Practice Address - Phone:937-258-6330
Practice Address - Fax:937-252-1242
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048185208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0496379Medicaid