Provider Demographics
NPI:1487963492
Name:MATHEW, PRINCE PANNIPUZHA (MD)
Entity type:Individual
Prefix:DR
First Name:PRINCE
Middle Name:PANNIPUZHA
Last Name:MATHEW
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:W131N6589 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-8315
Mailing Address - Country:US
Mailing Address - Phone:847-414-1171
Mailing Address - Fax:
Practice Address - Street 1:8901 W LINCOLN AVE
Practice Address - Street 2:AURORA HEALTH CARE
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2409
Practice Address - Country:US
Practice Address - Phone:414-429-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-26
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI57113-20207R00000X
WI57113208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine