Provider Demographics
NPI:1003019456
Name:REICHERT, SUSAN KAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KAREN
Last Name:REICHERT
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 1:125 NW GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-2913
Mailing Address - Country:US
Mailing Address - Phone:541-419-8743
Mailing Address - Fax:
Practice Address - Street 1:125 NW GREELEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2913
Practice Address - Country:US
Practice Address - Phone:541-419-8743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16007204D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE66314Medicare UPIN