Provider Demographics
NPI:1376515395
Name:LEIB, SUSAN MEZEY (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MEZEY
Last Name:LEIB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MEZEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8500-8735
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-3289
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:PALEY 1
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7170
Practice Address - Fax:215-456-4923
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD439546208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001306465Medicaid
CT001306465Medicaid