Provider Demographics
NPI:1639217276
Name:GRONDIN, SUZANNE MATTOS (DPM)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:MATTOS
Last Name:GRONDIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:MARIE
Other - Last Name:MATTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:123 SUMMER ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-363-6868
Mailing Address - Fax:508-363-6866
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 550
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-6868
Practice Address - Fax:508-363-6866
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2319213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0711772Medicaid
MA121815OtherFALLON HEALTH PLAN
MAY71137OtherBLUE SHEILD OF MA
MA466883OtherTUFTS HEALTH PLAN
MAAA84858OtherHARVARD PILGRIM HEALTH
MAY71137OtherBLUE SHEILD OF MA
MAAA84858OtherHARVARD PILGRIM HEALTH
MAV11876Medicare UPIN