Provider Demographics
NPI:1215910468
Name:MATHEW, DILLON KOSHY (PA C)
Entity type:Individual
Prefix:
First Name:DILLON
Middle Name:KOSHY
Last Name:MATHEW
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 210907
Mailing Address - Street 2:KANER MEDICAL GROUP
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76095-7907
Mailing Address - Country:US
Mailing Address - Phone:817-358-5800
Mailing Address - Fax:817-283-7686
Practice Address - Street 1:412 N MAIN ST
Practice Address - Street 2:STE 100
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-3652
Practice Address - Country:US
Practice Address - Phone:817-358-5800
Practice Address - Fax:817-283-7686
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA03223207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A3129Medicare ID - Type Unspecified
P79026Medicare UPIN