1639460827 NPI number — DR. JESNA SUSAN MATHEW SUBLETT MBBS

Table of content: DR. JESNA SUSAN MATHEW SUBLETT MBBS (NPI 1639460827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639460827 NPI number — DR. JESNA SUSAN MATHEW SUBLETT MBBS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUBLETT
Provider First Name:
JESNA
Provider Middle Name:
SUSAN MATHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MBBS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATHEW
Provider Other First Name:
JESNA
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MBBS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639460827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 STERTHAUS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174-5133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-231-3540
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 MEMORIAL MEDICAL PKWY STE 505
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32117-5170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-231-3540
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  ME149323 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110002000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".