Provider Demographics
NPI:1154322733
Name:MCMASTER, SUSAN M (D O)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MCMASTER
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:CO
Mailing Address - Zip Code:80809-0490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 ARBOR WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-2128
Practice Address - Country:US
Practice Address - Phone:719-471-6512
Practice Address - Fax:719-572-9033
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29909207Q00000X
HI632207Q00000X
KS05-23055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01299098Medicaid
CO01299098Medicaid
COC811135Medicare PIN
E60081Medicare UPIN