Provider Demographics
NPI:1154405272
Name:MATHEW, PUTHENPURACKAL (MD)
Entity type:Individual
Prefix:
First Name:PUTHENPURACKAL
Middle Name:
Last Name:MATHEW
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 1:330 23RD AVE N
Mailing Address - Street 2:SUITE 450
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1534
Mailing Address - Country:US
Mailing Address - Phone:615-342-7339
Mailing Address - Fax:615-342-7340
Practice Address - Street 1:330 23RD AVE N
Practice Address - Street 2:SUITE 450
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1534
Practice Address - Country:US
Practice Address - Phone:615-342-7339
Practice Address - Fax:615-342-7340
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD295092080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G63512Medicare UPIN