Basic Information
| Provider Information | |||||||||
| NPI: | 1710141346 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATHEW | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 CHERRY AVE | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983104229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604796154 | ||||||||
| FaxNumber: | 3604795728 | ||||||||
| Practice Location | |||||||||
| Address1: | 2720 CLARE AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604796154 | ||||||||
| FaxNumber: | 3604795728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2008 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | ME99988 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60277434 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001333300 | 05 | FL | MEDICAID |