Provider Demographics
NPI:1265493514
Name:BADARACCO, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:BADARACCO
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 1:2200 VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-3327
Mailing Address - Country:US
Mailing Address - Phone:972-317-6000
Mailing Address - Fax:972-317-6011
Practice Address - Street 1:2200 VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-3327
Practice Address - Country:US
Practice Address - Phone:972-317-6000
Practice Address - Fax:972-317-6011
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2841208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043544801Medicaid