Provider Demographics
NPI:1033186622
Name:MAHLE, SUSAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:MAHLE
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 1:12720 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6307
Mailing Address - Country:US
Mailing Address - Phone:763-559-2861
Mailing Address - Fax:763-559-1338
Practice Address - Street 1:12720 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6307
Practice Address - Country:US
Practice Address - Phone:763-559-2861
Practice Address - Fax:763-559-1338
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23762208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN920795300Medicaid
MNE35161Medicare UPIN