MEDICARE: NEVIN J MATHAI

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	122300000X	Dentist	019.032981	IL
2	122300000X	Dentist	2019020053	MO

General Provider Information

NPI Number	:	1558921858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEVIN J MATHAI

Provider Business Mailing Address
First Line	:	4935 ROBERT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-4002
Country	:	US
Telephone Number	:	224-388-7112
Fax Number	:

Provider Business Practice Location Address
First Line	:	5445 TELEGRAPH RD STE 111
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-3500
Country	:	US
Telephone Number	:	314-892-2120
Fax Number	:

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

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	05/02/2024

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Directions to “ NEVIN J MATHAI ” Practice Location

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