Healthcare Provider Details

I. General information

NPI: 1154395002
Provider Name (Legal Business Name): LINDA T MATHEW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LINDA A THOMAS

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2457 E MAIN ST
WATERBURY CT
06705-2685
US

IV. Provider business mailing address

1625 STRAITS TPKE SUITE #201
MIDDLEBURY CT
06762-1805
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-0169
  • Fax: 203-578-3420
Mailing address:
  • Phone: 203-573-9512
  • Fax: 203-568-2904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036123
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: