Provider Demographics
NPI:1114927118
Name:ANDERSON, SUSAN GARZA (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GARZA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN MARIE
Other - Middle Name:GARZA
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1311 WESTMONT CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7814
Mailing Address - Country:US
Mailing Address - Phone:214-458-1483
Mailing Address - Fax:
Practice Address - Street 1:1311 WESTMONT CT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7814
Practice Address - Country:US
Practice Address - Phone:214-458-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6461207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131144109Medicaid
TX131144113Medicaid
TX131144118Medicaid
TX131144112Medicaid
TX131144114Medicaid
TX131144121Medicaid
TX131144116Medicaid
TX131144122Medicaid
TX131144120Medicaid
TX131144110Medicaid
TX131144115Medicaid
TX131144119Medicaid
TX179236801Medicaid
TX8A0122OtherBLUE CROSS BLUE SHIELD
TX131144122Medicaid
TX131144109Medicaid
TX131144112Medicaid
TX8G4495Medicare PIN
TX179236801Medicaid