Healthcare Provider Details

I. General information

NPI: 1932280930
Provider Name (Legal Business Name): JINU JACOB MATHEW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E NORTH AVE
MILWAUKEE WI
53212-3515
US

IV. Provider business mailing address

1152 E WALWORTH ST
MILWAUKEE WI
53212-3521
US

V. Phone/Fax

Practice location:
  • Phone: 414-267-6500
  • Fax:
Mailing address:
  • Phone: 414-276-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49749
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: