Provider Demographics
NPI:1316068596
Name:THARAKAN, MATHEW ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:ALEXANDER
Last Name:THARAKAN
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:DEPT OF MEDICINE
Mailing Address - Street 2:HSC T16-020 STONY BROOK UNIVERSITY
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:641-444-8478
Mailing Address - Fax:
Practice Address - Street 1:DEPT OF MEDICINE
Practice Address - Street 2:HSC T16-020 STONY BROOK UNIVERSITY
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:641-444-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243023207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid