Provider Demographics
NPI:1992384556
Name:MATHEW, SHANE KORAH (MD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:KORAH
Last Name:MATHEW
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 1:5301 BUTTERNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-4690
Mailing Address - Country:US
Mailing Address - Phone:216-225-8270
Mailing Address - Fax:
Practice Address - Street 1:675 HOES LN W
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-8021
Practice Address - Country:US
Practice Address - Phone:732-828-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program