Provider Demographics
NPI:1073513255
Name:WEISBERG, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:WEISBERG
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 1:1400 DOWELL SPRINGS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2456
Mailing Address - Country:US
Mailing Address - Phone:865-584-0291
Mailing Address - Fax:865-584-4426
Practice Address - Street 1:1400 DOWELL SPRINGS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2456
Practice Address - Country:US
Practice Address - Phone:865-584-0291
Practice Address - Fax:865-584-4426
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0055048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371685600Medicaid
FL371685600Medicaid
FLE85411Medicare UPIN