Healthcare Provider Details

I. General information

NPI: 1154556637
Provider Name (Legal Business Name): PREMILA MARIA MATHEWS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1894 WALTON AVE
BRONX NY
10453-6018
US

IV. Provider business mailing address

1894 WALTON AVE
BRONX NY
10453-6018
US

V. Phone/Fax

Practice location:
  • Phone: 718-583-3060
  • Fax: 718-583-3360
Mailing address:
  • Phone: 718-583-3060
  • Fax: 718-583-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number267709
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: