Healthcare Provider Details

I. General information

NPI: 1558110726
Provider Name (Legal Business Name): BENNY K MATHEW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 NEW HEMPSTEAD RD
NEW CITY NY
10956-3627
US

IV. Provider business mailing address

695 LITTLE BRITAIN RD
NEW WINDSOR NY
12553-6152
US

V. Phone/Fax

Practice location:
  • Phone: 845-638-5615
  • Fax:
Mailing address:
  • Phone: 347-409-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF351816
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number633719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: