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: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AS100
JACKSONVILLE NC
28542-1034
US

IV. Provider business mailing address

AS 100,PSC BOX 21034 MAG 29 MCAS NEW RIVER NC
JACKSONVILLE NC
28542-1034
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-6500
  • Fax:
Mailing address:
  • Phone: 910-449-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number59999-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5999-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number59999-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number59999-20
License Number StateWI
# 5
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number59999-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: