Healthcare Provider Details

I. General information

NPI: 1770726549
Provider Name (Legal Business Name): JEEJI YOHANNAN MATHUNNY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2079 FOREST AVE
STATEN ISLAND NY
10303-1735
US

IV. Provider business mailing address

2079 FOREST AVE
STATEN ISLAND NY
10303-1865
US

V. Phone/Fax

Practice location:
  • Phone: 718-815-6560
  • Fax:
Mailing address:
  • Phone: 718-815-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number252669
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: