Provider Demographics
NPI:1376197483
Name:MATHEW, BLESSY SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BLESSY
Middle Name:SUSAN
Last Name:MATHEW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44239 LA DOMAIN DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1974
Mailing Address - Country:US
Mailing Address - Phone:586-215-4124
Mailing Address - Fax:
Practice Address - Street 1:44987 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1141
Practice Address - Country:US
Practice Address - Phone:586-247-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist