Healthcare Provider Details

I. General information

NPI: 1346535838
Provider Name (Legal Business Name): MANOJ MATHEW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 SAVAGE RD
FORT GEORGE G MEADE MD
20755-5999
US

IV. Provider business mailing address

11500 ALCINDA LN
NORTH POTOMAC MD
20878-2427
US

V. Phone/Fax

Practice location:
  • Phone: 443-479-0353
  • Fax:
Mailing address:
  • Phone: 713-530-8665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0505X
TaxonomyDiabetology (Internal Medicine) Physician
License NumberD0105915
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License NumberD0105915
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberD0105915
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0105915
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD0105915
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5999-20
License Number StateWI
# 7
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number59999-20
License Number StateWI
# 8
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number59999-20
License Number StateWI
# 9
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number59999-20
License Number StateWI
# 10
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number59999-20
License Number StateWI
# 11
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberD0105915
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: