Provider Demographics
NPI:1336111491
Name:BUENAVENTURA, SUSAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:BUENAVENTURA
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 1:5425 DUKE STREET
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304
Mailing Address - Country:US
Mailing Address - Phone:703-751-0800
Mailing Address - Fax:703-751-4378
Practice Address - Street 1:5425 DUKE STREET
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-751-0800
Practice Address - Fax:703-751-4378
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010512132086S0122X
NC94007352086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA184854OtherANTHEM
4819OtherBC BS NCA
VAG02274T01Medicare ID - Type Unspecified
4819OtherBC BS NCA