Provider Demographics
NPI:1235119686
Name:GARSTANG, SUSAN V (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:V
Last Name:GARSTANG
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 1:500 FOOTHILL BLVD # MC11E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84148-0001
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:801-584-2584
Practice Address - Street 1:500 FOOTHILL BLVD # MC11E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-2584
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ95032081P0004X
NJ25MA068287002081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK00003612Medicaid
G95984Medicare UPIN
NJ094907Medicare ID - Type Unspecified