Provider Demographics
NPI:1588987440
Name:MATHEW, SHAJI
Entity type:Individual
Prefix:
First Name:SHAJI
Middle Name:
Last Name:MATHEW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 FILLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLNAD
Mailing Address - State:NY
Mailing Address - Zip Code:10314
Mailing Address - Country:US
Mailing Address - Phone:718-983-5657
Mailing Address - Fax:718-983-5657
Practice Address - Street 1:540 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:MANHATTEN
Practice Address - State:NY
Practice Address - Zip Code:10024
Practice Address - Country:US
Practice Address - Phone:212-712-2821
Practice Address - Fax:212-875-8778
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist