Provider Demographics
NPI:1033118898
Name:SUSEC, OTTO C JR (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:C
Last Name:SUSEC
Suffix:JR
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 1:5402 PHEASANT DR.
Mailing Address - Street 2:
Mailing Address - City:N. MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582
Mailing Address - Country:US
Mailing Address - Phone:843-390-0168
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:843-497-9940
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065993A208D00000X
SC18388207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT23285Medicaid
SCT23285Medicaid
SCG221955373Medicare PIN