Provider Demographics
NPI:1043281959
Name:MIESFELDT, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MIESFELDT
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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:100 CAMPUS DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074
Practice Address - Country:US
Practice Address - Phone:207-396-7678
Practice Address - Fax:207-396-8766
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD16381207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204925OtherNH MEDICAID
ME7429082OtherAETNA
ME7338683OtherCIGNA
ME277890099Medicaid
ME3394475OtherAETNA HMO
ME022168OtherANTHEM BCBS
MEP00142224OtherRAILROAD MEDICARE
MEP00142224OtherRAILROAD MEDICARE
NH30204925OtherNH MEDICAID
MEME089102Medicare PIN
B77087Medicare UPIN
ME022168OtherANTHEM BCBS