Healthcare Provider Details

I. General information

NPI: 1497504260
Provider Name (Legal Business Name): MANU MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7403 COMMONWEALTH BLVD
BELLEROSE NY
11426-1839
US

IV. Provider business mailing address

7403 COMMONWEALTH BLVD
BELLEROSE NY
11426-1839
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-4500
  • Fax:
Mailing address:
  • Phone: 718-264-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number758201-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: