Provider Demographics
NPI:1043411341
Name:DOUGLAS, SUSAN STANTON (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:STANTON
Last Name:DOUGLAS
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 1:2 EASTGATE AVE
Mailing Address - Street 2:
Mailing Address - City:MONESSEN
Mailing Address - State:PA
Mailing Address - Zip Code:15062-1393
Mailing Address - Country:US
Mailing Address - Phone:724-684-6489
Mailing Address - Fax:724-684-7116
Practice Address - Street 1:2 EASTGATE AVE
Practice Address - Street 2:
Practice Address - City:MONESSEN
Practice Address - State:PA
Practice Address - Zip Code:15062-1393
Practice Address - Country:US
Practice Address - Phone:724-684-6489
Practice Address - Fax:724-684-7116
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4294982084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023068350001Medicaid