Provider Demographics
NPI:1104299452
Name:MATHEW, MATHEW UDO
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:UDO
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 ODD FELLOWS RD
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-2214
Mailing Address - Country:US
Mailing Address - Phone:337-783-8316
Mailing Address - Fax:
Practice Address - Street 1:806 ODD FELLOWS RD
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-2214
Practice Address - Country:US
Practice Address - Phone:337-783-8316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist