Provider Demographics
NPI:1316098858
Name:MATHAI, GEORGE THOTTAKARA (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOTTAKARA
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 1:224 LONG ST
Mailing Address - Street 2:
Mailing Address - City:NEW JOHNSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37134-2468
Mailing Address - Country:US
Mailing Address - Phone:931-535-3734
Mailing Address - Fax:931-535-3742
Practice Address - Street 1:224 LONG ST
Practice Address - Street 2:
Practice Address - City:NEW JOHNSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37134-2468
Practice Address - Country:US
Practice Address - Phone:931-535-3734
Practice Address - Fax:931-535-3742
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4074799OtherBLUE CROSS BLUE SHIELD TN
TN3889576Medicaid
TN4074799OtherBLUE CROSS BLUE SHIELD TN
TN38895761Medicare PIN