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General NPI Number Information
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NPI Number | 1598988305
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Entity Type | Individual
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Provider Name | DR. MARK STEPHEN MATHUSA JR.
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Gender | Male
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 785 JUPITER BLVD NW
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City | PALM BAY
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State | FL
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Zip | 32907-8209
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Country | US
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Telephone | 321-952-4315
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Fax | 321-952-2222
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Provider Business Mailing Address
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Address Line | 175 ELFIN ST
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City | PALM BAY
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State | FL
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Zip | 32909
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Country | US
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Telephone | 321-952-4315
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Fax | 321-952-2222
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174M00000X
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Taxonomy Name | Veterinarian
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License Number | 4637
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License Number State | FL
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