Healthcare Provider Details

I. General information

NPI: 1619720331
Provider Name (Legal Business Name): SHELBIN JACOB MATTATHIL MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 CITY CENTRAL AVE
CONROE TX
77304-2981
US

IV. Provider business mailing address

156 WEDGEWOOD WAY
LUCAS TX
75002-7480
US

V. Phone/Fax

Practice location:
  • Phone: 936-202-5202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: