Provider Demographics
NPI:1225004278
Name:TENOLD, SUSAN MARIE ROBERTS (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE ROBERTS
Last Name:TENOLD
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:PO BOX 61896
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-1896
Mailing Address - Country:US
Mailing Address - Phone:360-823-2012
Mailing Address - Fax:360-823-2260
Practice Address - Street 1:3200 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-696-4691
Practice Address - Fax:360-823-2260
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020750207W00000X
ORMD12382207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8458903Medicaid
WA8458903Medicaid
A08152Medicare UPIN
WA8458903Medicaid
WA000681800Medicare PIN