Provider Demographics
NPI:1336290782
Name:MILLAN, SUSAN BONKEMEYER (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:BONKEMEYER
Last Name:MILLAN
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 1:4830 NW 43RD ST
Mailing Address - Street 2:APT G104
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-4401
Mailing Address - Country:US
Mailing Address - Phone:352-215-3261
Mailing Address - Fax:
Practice Address - Street 1:3951 NW 48TH TER
Practice Address - Street 2:SUITE 211
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7228
Practice Address - Country:US
Practice Address - Phone:352-265-4450
Practice Address - Fax:352-265-4451
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA69357207Q00000X
FLME530602083P0011X
FL53060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002823500Medicaid
FL002823500Medicaid