Provider Demographics
NPI:1114091675
Name:DUBOIS, SUSAN KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:DUBOIS
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 1:2901 MONTOPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-6411
Mailing Address - Country:US
Mailing Address - Phone:512-978-9901
Mailing Address - Fax:512-901-9765
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-978-9901
Practice Address - Fax:512-901-9765
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6178207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147296102Medicaid
8U0684OtherOLD BLUE CROSS #
743009528OtherGROUP TAX ID
8X7501OtherNEW BLUE CROSS #
TX8571J0Medicare PIN
8U0684OtherOLD BLUE CROSS #