Provider Demographics
NPI:1255486296
Name:LJUNGHAG, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:LJUNGHAG
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 1:4900 S MONACO ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-788-6657
Mailing Address - Fax:303-788-8837
Practice Address - Street 1:10103 RIDGEGATE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5525
Practice Address - Country:US
Practice Address - Phone:303-788-6657
Practice Address - Fax:303-788-8837
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25658174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01256585Medicaid
CO160054944OtherRAILROAD MEDICARE
CO01256585Medicaid
CO460622YTU0Medicare PIN
COC364198Medicare PIN
CO160054944OtherRAILROAD MEDICARE