Provider Demographics
NPI:1275595159
Name:SUSKO, KEITH S (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:SUSKO
Suffix:
Gender:M
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 222
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33929-0222
Mailing Address - Country:US
Mailing Address - Phone:239-226-0077
Mailing Address - Fax:239-489-0077
Practice Address - Street 1:4977 ROYAL GULF CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-7006
Practice Address - Country:US
Practice Address - Phone:239-226-0077
Practice Address - Fax:239-489-0077
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85368208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17033OtherBCBS
FL17033XOtherMEDICARE
FL2658666-00Medicaid
FL2658666-00Medicaid