Provider Demographics
NPI:1730149725
Name:CHRYSSIADIS, MARY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:CHRYSSIADIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:16401 SW FARMS ROAD
Mailing Address - City:INDIANTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:34956-0267
Mailing Address - Country:US
Mailing Address - Phone:772-597-3687
Mailing Address - Fax:772-597-4604
Practice Address - Street 1:3441 SE WILLOUGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5060
Practice Address - Country:US
Practice Address - Phone:772-597-3687
Practice Address - Fax:772-597-4604
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 69427208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG54955OtherMEDICAL LICENSE
FLME69427OtherMEDICAL LICENSE
FLG17417Medicare UPIN