Provider Demographics
NPI:1164558433
Name:SUSAN V. ESTRADA, MD, PC
Entity Type:Organization
Organization Name:SUSAN V. ESTRADA, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:ESTRADA-TE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-347-0861
Mailing Address - Street 1:13 STONEY BROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-7803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:239 EDGEWOOD DRIVE EXTENSION
Practice Address - Street 2:
Practice Address - City:TRANSFER
Practice Address - State:PA
Practice Address - Zip Code:16154
Practice Address - Country:US
Practice Address - Phone:724-646-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 062293 L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016769370007Medicaid