Provider Demographics
NPI:1386798452
Name:MATHAN, SUKUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:SUKUMAR
Middle Name:
Last Name:MATHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35600 HWY 27
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-3731
Mailing Address - Country:US
Mailing Address - Phone:863-866-9820
Mailing Address - Fax:863-812-4455
Practice Address - Street 1:35600 US HWY 27 NORTH
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-3731
Practice Address - Country:US
Practice Address - Phone:863-866-9820
Practice Address - Fax:863-812-4455
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80845207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259693800Medicaid
FL259693800Medicaid
FL35862YMedicare ID - Type Unspecified