Provider Demographics
NPI:1033166038
Name:ELIZONDO, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:ELIZONDO
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 370
Mailing Address - Street 2:359-A WEST HIGHWAY 264
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0370
Mailing Address - Country:US
Mailing Address - Phone:928-810-3800
Mailing Address - Fax:928-810-3801
Practice Address - Street 1:359-A WEST HIGHWAY 264
Practice Address - Street 2:
Practice Address - City:ST MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511-0370
Practice Address - Country:US
Practice Address - Phone:928-810-3800
Practice Address - Fax:928-810-3801
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z135040OtherMEDICARE PTAN
AZ156365Medicaid