Provider Demographics
NPI:1366641672
Name:MOOSE, SUSAN CAROL (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CAROL
Last Name:MOOSE
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Gender:F
Credentials:DO
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Mailing Address - Street 1:136 LINDEN DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6900
Mailing Address - Country:US
Mailing Address - Phone:540-678-3588
Mailing Address - Fax:540-678-9025
Practice Address - Street 1:759 S MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:WOODSTOCK
Practice Address - State:VA
Practice Address - Zip Code:22664-1127
Practice Address - Country:US
Practice Address - Phone:540-459-1540
Practice Address - Fax:540-459-1486
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2021-03-04
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Provider Licenses
StateLicense IDTaxonomies
VA0116017646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA018154W52Medicare PIN