Provider Demographics
NPI:1992082721
Name:MATHEW MEDICAL CONSULTING PA
Entity type:Organization
Organization Name:MATHEW MEDICAL CONSULTING PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLIVEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-210-0132
Mailing Address - Street 1:635 TUSCANNY ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6165
Mailing Address - Country:US
Mailing Address - Phone:239-210-0132
Mailing Address - Fax:239-210-0134
Practice Address - Street 1:635 TUSCANNY ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6165
Practice Address - Country:US
Practice Address - Phone:239-210-0132
Practice Address - Fax:239-210-0134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000612200Medicaid