Provider Demographics
NPI:1982705711
Name:MATHEW, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
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 1:131-13 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SO OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420
Mailing Address - Country:US
Mailing Address - Phone:718-322-1122
Mailing Address - Fax:718-322-4505
Practice Address - Street 1:131-13 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SO OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420
Practice Address - Country:US
Practice Address - Phone:718-322-1122
Practice Address - Fax:718-322-4505
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117668208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00218608Medicaid
E12813Medicare UPIN