Provider Demographics
NPI:1770863797
Name:SUSAN MATHEW, JITHU (MD)
Entity Type:Individual
Prefix:
First Name:JITHU
Middle Name:
Last Name:SUSAN 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 1:27200 IRIS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4803
Mailing Address - Country:US
Mailing Address - Phone:866-984-7483
Mailing Address - Fax:
Practice Address - Street 1:27200 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4803
Practice Address - Country:US
Practice Address - Phone:866-984-7483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127943207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine