Provider Demographics
NPI:1184686719
Name:YEAGLEY, SUSANNE CAROL (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:CAROL
Last Name:YEAGLEY
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 1:2100 HEDGCOXE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-3163
Mailing Address - Country:US
Mailing Address - Phone:972-769-8443
Mailing Address - Fax:972-769-2395
Practice Address - Street 1:2100 HEDGCOXE RD STE 120
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-3163
Practice Address - Country:US
Practice Address - Phone:972-769-8443
Practice Address - Fax:972-769-2395
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102158604Medicaid
TX8B4288OtherBCBS
TX102158605Medicaid
TX080177675OtherRR MEDICARE
TX102158603Medicaid
TX102158606Medicaid
TXE16412Medicare UPIN
TX102158605Medicaid
TXTXB113167Medicare PIN
TX102158603Medicaid
TX102158604Medicaid