Provider Demographics
NPI:1356304091
Name:AVERITT, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:AVERITT
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 1:5501 WILLOW CREEK DR. STE 203
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-757-8099
Mailing Address - Fax:
Practice Address - Street 1:5501 WILLOW CREEK DR. STE 203
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-575-9359
Practice Address - Fax:479-575-9415
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23620208000000X
ARE2459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1324230001OtherPALMETTO DME
MO1356304091Medicaid
OK74502A050OtherCHAMPUS (WPS)
OKH14901OtherSTERLING OPTION 1
OK200016780AMedicaid
OK731310891028OtherTRICARE SOUTH
OK200016780AOtherSOONER PCP
AR140067001Medicaid
OK731310891028OtherTRICARE SOUTH
OK200016780AMedicaid