Provider Demographics
NPI:1881129385
Name:MATHEW, ALICE (DO)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 GOLF MEADOW BLVD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7297
Mailing Address - Country:US
Mailing Address - Phone:813-482-4931
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-22
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11977200207R00000X
NY304919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine