Provider Demographics
NPI:1962745331
Name:MATHEW, BOBBY VARGHESE
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:VARGHESE
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 1:7233 ANTARES DR
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-5429
Mailing Address - Country:US
Mailing Address - Phone:410-241-4608
Mailing Address - Fax:
Practice Address - Street 1:6565 N CHARLES ST STE 411
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-5803
Practice Address - Country:US
Practice Address - Phone:443-849-3901
Practice Address - Fax:443-849-3902
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.207130208M00000X
MDD0089867207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2329201Medicaid