Provider Demographics
NPI:1093726192
Name:THOMAS, SUSANNA (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:
Last Name:THOMAS
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 1:1250 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4405
Mailing Address - Country:US
Mailing Address - Phone:860-388-9250
Mailing Address - Fax:860-388-9687
Practice Address - Street 1:1250 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-4405
Practice Address - Country:US
Practice Address - Phone:860-388-9250
Practice Address - Fax:860-388-9687
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010028170CT01OtherANTHEM BLUE SHIELD
CT028170OtherCONNECTICARE
CT2143945OtherAETNA
CT0R0177OtherHEALTHNET
CT080121849OtherRAILROAD MEDICARE
CT0R0177OtherHEALTHNET
CT028170OtherCONNECTICARE