Provider Demographics
NPI:1104856608
Name:MATHAI, ALEXANDER P (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:P
Last Name:MATHAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12515 GOLDEN HARVEST DR
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9031
Mailing Address - Country:US
Mailing Address - Phone:217-714-0220
Mailing Address - Fax:260-387-6194
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-526-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062241208M00000X
IN01062241A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11589278OtherCAQH
IN000000485120OtherANTHEM
OH2680111Medicaid
IN200827920Medicaid
POO390087OtherRAILROAD
IN000000485120OtherANTHEM
OH2680111Medicaid
IN11589278OtherCAQH