Provider Demographics
NPI:1043292733
Name:MATTISON, SUSAN B (DPM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:MATTISON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3695 W BOYNTON BEACH BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-4516
Mailing Address - Country:US
Mailing Address - Phone:561-364-5522
Mailing Address - Fax:
Practice Address - Street 1:3695 W BOYNTON BEACH BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-4516
Practice Address - Country:US
Practice Address - Phone:561-364-5522
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1924213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT87856Medicare UPIN
FL65094ZMedicare ID - Type Unspecified