Provider Demographics
NPI:1235101015
Name:BARCELLOS, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:BARCELLOS
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 1:409 SILVERADO PT
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8150
Mailing Address - Country:US
Mailing Address - Phone:515-987-0357
Mailing Address - Fax:
Practice Address - Street 1:710 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE CENTER
Practice Address - State:IA
Practice Address - Zip Code:50115-1544
Practice Address - Country:US
Practice Address - Phone:641-332-2201
Practice Address - Fax:641-332-2276
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAE967472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA25708OtherWELLMARK
IAIA0122OtherJOHN DEERE
IA3075879Medicaid
IA25708OtherWELLMARK
IAE96747Medicare UPIN