=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720209885
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOJY MATTACKAL GEORGE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3333 BAYSHORE BLVD STE 260
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77504-1961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-991-6117
-----------------------------------------------------
Fax | 888-812-8191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3820 NORTHDALE BLVD STE 201
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33624-1893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-991-6117
-----------------------------------------------------
Fax | 888-812-8191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | N2524
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2010028267
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | N2524
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------