Healthcare Provider Details

I. General information

NPI: 1467572107
Provider Name (Legal Business Name): MANOJ MATHEW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 E BELL RD STE 107
PHOENIX AZ
85032-2158
US

IV. Provider business mailing address

5151 E BROADWAY RD STE 107
MESA AZ
85206-1346
US

V. Phone/Fax

Practice location:
  • Phone: 602-340-1689
  • Fax: 602-340-1853
Mailing address:
  • Phone: 480-290-7000
  • Fax: 602-254-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number33087
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number33087
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: