Provider Demographics
NPI:1356488928
Name:HOLEC-IWASKO, SUSAN MARIE (DO)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MARIE
Last Name:HOLEC-IWASKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:HOLEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 USA PKWY STE A100
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9255
Practice Address - Country:US
Practice Address - Phone:317-678-3850
Practice Address - Fax:317-968-1142
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0200207Q00000X
IN02001359A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000173793OtherANTHEM PIN
IN264430H57OtherMEDICARE PTAN
IN4299039OtherAETNA PIN
IN100218910Medicaid