Provider Demographics
NPI:1770522534
Name:MATHEW, SUSHILA M (MD)
Entity type:Individual
Prefix:
First Name:SUSHILA
Middle Name:M
Last Name:MATHEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSHILA
Other - Middle Name:MARY
Other - Last Name:MATHEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:193 NORTH PARK TRAIL
Mailing Address - Street 2:STE 100
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-389-0116
Mailing Address - Fax:770-389-4058
Practice Address - Street 1:193 N PARK TRL
Practice Address - Street 2:STE 100
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:770-389-0116
Practice Address - Fax:770-389-4058
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022250208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
727104Medicare UPIN