Provider Demographics
NPI:1295848265
Name:MAHONEY, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MAHONEY
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:PO BOX 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-378-2141
Mailing Address - Fax:360-378-3655
Practice Address - Street 1:1117 SPRING ST
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-8057
Practice Address - Country:US
Practice Address - Phone:360-378-2141
Practice Address - Fax:360-378-3655
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034157174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1295848265OtherREGENCY BLUE SHIELD
WA1295848265Medicaid
WA8209199Medicaid
WA1295848265OtherTRI-WEST (TRICARE)
WAG8912396Medicare PIN
WAAB01110Medicare UPIN
WA1295848265OtherTRI-WEST (TRICARE)