Provider Demographics
NPI:1770675480
Name:MATHEW, SUSAN P (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:P
Last Name:MATHEW
Suffix:
Gender:F
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:P.O. BOX 9671
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9671
Mailing Address - Country:US
Mailing Address - Phone:386-676-7130
Mailing Address - Fax:386-676-7125
Practice Address - Street 1:201 CLYDE MORRIS BLVD.
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-676-7130
Practice Address - Fax:386-676-7125
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031212207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4041679Medicaid
060646704OtherTRI-CARE
CT4024972Medicaid
CT1770675480Medicaid
CT010031212CTOtherANTHEM
060646704OtherTRI-CARE
CT1770675480Medicaid
CT010031212CTOtherANTHEM
CT4024972Medicaid