Provider Demographics
NPI:1326010521
Name:MORAN, SUSAN OTT (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:OTT
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JOYCE
Other - Last Name:OTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:ATTN: 21 MDG/CC
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1540
Mailing Address - Country:US
Mailing Address - Phone:719-556-1250
Mailing Address - Fax:866-867-7926
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:ATTN: 21 MDG/CC
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1540
Practice Address - Country:US
Practice Address - Phone:719-556-1250
Practice Address - Fax:866-867-7926
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063582L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics