Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 2951000843 | MI |
Y | 213EG0000X | General Practice | 2951000843 | MI |
NPI | 1003492281 |
---|---|
Provider Name | Shawn Mathew |
First Address | Detroit, MI 48208-2576 |
Second Address | Detroit, MI 48208-2576 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2021 |
Last Update Date | 02/08/2021 |