Healthcare Provider Details

I. General information

NPI: 1508813924
Provider Name (Legal Business Name): SHIRLEY MATHEW MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 N RICHMOND AVE
MASSAPEQUA NY
11758-3438
US

IV. Provider business mailing address

1000 NORTHERN BLVD SUITE 300
GREAT NECK NY
11021-5312
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-8777
  • Fax: 516-829-7926
Mailing address:
  • Phone: 516-829-8777
  • Fax: 519-829-7926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number196418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: