Provider Demographics
NPI:1346216975
Name:BUNNELL, SUSAN LYNN (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LYNN
Last Name:BUNNELL
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 1:2280 E 25TH STREET
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-227-2295
Mailing Address - Fax:208-227-2364
Practice Address - Street 1:2280 E 25TH STREET
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-227-2295
Practice Address - Fax:208-227-2364
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD55762084P0804X
IDM111542084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID13426216975Medicaid
SD4994379OtherBCBS
SD7101880Medicaid
D24169Medicare UPIN
510539072Medicare ID - Type Unspecified