MEDICARE: DR. KOLATHU A MATHEW M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	111422	NY

General Provider Information

NPI Number	:	1083744171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KOLATHU A MATHEW M.D.

Provider Business Mailing Address
First Line	:	720 MONTAUK HWY
Second Line	:
City	:	WEST ISLIP
State	:	NY
Zip	:	11795-4411
Country	:	US
Telephone Number	:	631-669-2900
Fax Number	:	631-669-2547

Provider Business Practice Location Address
First Line	:	720 MONTAUK HWY
Second Line	:
City	:	WEST ISLIP
State	:	NY
Zip	:	11795-4411
Country	:	US
Telephone Number	:	631-669-2900
Fax Number	:	631-669-2547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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