Provider Demographics
NPI:1154556637
Name:MATHEWS, PREMILA MARIA (MD)
Entity type:Individual
Prefix:
First Name:PREMILA
Middle Name:MARIA
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1894 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-6018
Mailing Address - Country:US
Mailing Address - Phone:718-583-3060
Mailing Address - Fax:718-583-3360
Practice Address - Street 1:1894 WALTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-6018
Practice Address - Country:US
Practice Address - Phone:718-583-3060
Practice Address - Fax:718-583-3360
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267709207Q00000X, 207Q00000X
PAMT195687390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03554881Medicaid