Healthcare Provider Details

I. General information

NPI: 1730149725
Provider Name (Legal Business Name): MARY CHRYSSIADIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3441 SE WILLOUGHBY BLVD
STUART FL
34994-5060
US

IV. Provider business mailing address

PO BOX 267 16401 SW FARMS ROAD
INDIANTOWN FL
34956-0267
US

V. Phone/Fax

Practice location:
  • Phone: 772-597-3687
  • Fax: 772-597-4604
Mailing address:
  • Phone: 772-597-3687
  • Fax: 772-597-4604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 69427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: