Provider Demographics
NPI:1326036344
Name:FEDERINKO, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:FEDERINKO
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 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:BUILDING 830
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-1942
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:BUILDING 830
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-1942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079092207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine