Provider Demographics
NPI:1053373159
Name:MATHUR, PRADEEP (MD)
Entity type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:
Last Name:MATHUR
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 1:955 WINDHAM CT
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5035
Mailing Address - Country:US
Mailing Address - Phone:330-726-9570
Mailing Address - Fax:330-726-9031
Practice Address - Street 1:955 WINDHAM CT
Practice Address - Street 2:SUITE 2
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5035
Practice Address - Country:US
Practice Address - Phone:330-726-9570
Practice Address - Fax:330-726-9031
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.05.96512084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMA0674889Medicare ID - Type UnspecifiedMEDICARE NUMBER