Healthcare Provider Details

I. General information

NPI: 1093820953
Provider Name (Legal Business Name): ROSHAN K. MATHEW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 FAIRVIEW DR
OWENSBORO KY
42303-2175
US

IV. Provider business mailing address

2609 NEW HARTFORD RD
OWENSBORO KY
42303-1316
US

V. Phone/Fax

Practice location:
  • Phone: 270-240-2129
  • Fax:
Mailing address:
  • Phone: 270-240-1747
  • Fax: 270-240-1748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39846
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number39846
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: