Healthcare Provider Details

I. General information

NPI: 1962745331
Provider Name (Legal Business Name): BOBBY VARGHESE MATHEW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST STE 411
TOWSON MD
21204-5803
US

IV. Provider business mailing address

7233 ANTARES DR
GAITHERSBURG MD
20879-5429
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-3901
  • Fax: 443-849-3902
Mailing address:
  • Phone: 410-241-4608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD.207130
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberD0089867
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: