Provider Demographics
NPI:1508831702
Name:MATTHYS-OLLODART, SUSANNE E (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:E
Last Name:MATTHYS-OLLODART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:
Other - Last Name:MATTHYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1530 S UNION AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1954
Mailing Address - Country:US
Mailing Address - Phone:253-759-3333
Mailing Address - Fax:253-759-1415
Practice Address - Street 1:1530 S UNION AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1954
Practice Address - Country:US
Practice Address - Phone:253-759-3333
Practice Address - Fax:253-759-1415
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035005208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8208092Medicaid
WA8208092Medicaid