Provider Demographics
NPI:1003818683
Name:SUSOTT, KIRK L (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:L
Last Name:SUSOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:OSCAR G. JOHNSON VA MEDICAL CENTER
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:906-779-3124
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:OSCAR G. JOHNSON VA MEDICAL CENTER
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:906-779-3124
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301039087208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4758301Medicaid
MI4777174Medicaid
B47544Medicare UPIN
MI4777174Medicaid