Provider Demographics
NPI:1043266224
Name:STAUDT, SUSAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:STAUDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1912 FREMONT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2932
Mailing Address - Country:US
Mailing Address - Phone:414-704-1929
Mailing Address - Fax:
Practice Address - Street 1:B515 MAYO MEMORIAL BUILDING
Practice Address - Street 2:420 DELAWARE ST SE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-624-9990
Practice Address - Fax:612-626-2363
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43128207LP3000X, 207L00000X
MN66314207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043266224Medicaid
006006261KOtherHUMANA
WI014M 73-601Medicare PIN
G08141Medicare UPIN