MEDICARE: SUSAN B MATTISON D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	PO1924	FL

General Provider Information

NPI Number	:	1043292733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN B MATTISON D.P.M.

Provider Business Mailing Address
First Line	:	3695 W BOYNTON BEACH BLVD
Second Line	:	SUITE 4
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-4516
Country	:	US
Telephone Number	:	561-364-5522
Fax Number	:

Provider Business Practice Location Address
First Line	:	3695 W BOYNTON BEACH BLVD
Second Line	:	SUITE 4
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-4516
Country	:	US
Telephone Number	:	561-364-5522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	07/08/2007

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