Provider Demographics
NPI:1326091646
Name:BRANDT, SUSAN JEAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JEAN
Last Name:BRANDT
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 1:5026 PETERS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-7276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5026 PETERS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-7276
Practice Address - Country:US
Practice Address - Phone:352-442-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87372207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71376OtherBLUE CROSS BLUE SHIELD
FL71376WOtherRAILROAD MEDICARE
FLG15928Medicare UPIN
FL71376OtherBLUE CROSS BLUE SHIELD