Provider Demographics
NPI:1982098463
Name:MATHEW, MERRILL
Entity Type:Individual
Prefix:DR
First Name:MERRILL
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 1ST ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5117
Mailing Address - Country:US
Mailing Address - Phone:475-323-4326
Mailing Address - Fax:475-325-6217
Practice Address - Street 1:28 1ST ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5117
Practice Address - Country:US
Practice Address - Phone:475-323-4326
Practice Address - Fax:475-325-6217
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT622072084F0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program