Provider Demographics
NPI:1730165853
Name:GEEVARGHESE, MATHULLA (MD)
Entity type:Individual
Prefix:DR
First Name:MATHULLA
Middle Name:
Last Name:GEEVARGHESE
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 1:1101 N-W-134 AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2914
Mailing Address - Country:US
Mailing Address - Phone:954-846-7588
Mailing Address - Fax:
Practice Address - Street 1:1101
Practice Address - Street 2:N.W -134 AVENUE
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2914
Practice Address - Country:US
Practice Address - Phone:954-846-7588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63605208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372687800Medicaid
FL372687800Medicaid