1609211069 NPI number — DR. JUDITH DEL CARMEN MATHURA M.D.

Table of content: DR. JUDITH DEL CARMEN MATHURA M.D. (NPI 1609211069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609211069 NPI number — DR. JUDITH DEL CARMEN MATHURA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHURA
Provider First Name:
JUDITH
Provider Middle Name:
DEL CARMEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUTIERREZ
Provider Other First Name:
JUDITH
Provider Other Middle Name:
DEL CARMEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609211069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 POND CT STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEBARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32713-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-259-4106
Provider Business Mailing Address Fax Number:
866-554-1654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 POND CT STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEBARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32713-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-259-4106
Provider Business Practice Location Address Fax Number:
866-554-1654
Provider Enumeration Date:
04/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME115042 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103840200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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