Healthcare Provider Details

I. General information

NPI: 1669416657
Provider Name (Legal Business Name): AJITA MATHUR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

101 E OLNEY AVENUE SUITE 400
PHILADELPHIA PA
19120-2470
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-9850
  • Fax:
Mailing address:
  • Phone: 215-254-2630
  • Fax: 215-254-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number217562
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: