Provider Demographics
NPI:1073593539
Name:OSULLIVAN, SUSAN GOLDA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:GOLDA
Last Name:OSULLIVAN
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 1:4900 COX ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:804-346-1747
Mailing Address - Fax:804-346-1704
Practice Address - Street 1:4900 COX ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:804-346-1747
Practice Address - Fax:804-346-1704
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010544112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06703OtherMEDICARE GROUP
VAC06703OtherMEDICARE GROUP
G82613Medicare UPIN