Provider Demographics
NPI:1285630947
Name:PAKULA, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:PAKULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 COMMERCE ST
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1168
Mailing Address - Country:US
Mailing Address - Phone:401-793-8484
Mailing Address - Fax:401-793-8481
Practice Address - Street 1:1 COMMERCE ST
Practice Address - Street 2:PEDIATRICS
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1168
Practice Address - Country:US
Practice Address - Phone:401-793-8484
Practice Address - Fax:401-793-8481
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
RIMD055252080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7003061Medicaid
MA2067871Medicaid
RI7003061Medicaid
RI7008161Medicare PIN