Provider Demographics
NPI:1376867937
Name:SUSAN VAN DE WATER, MD, PA
Entity Type:Organization
Organization Name:SUSAN VAN DE WATER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VAN DE WATER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-570-0373
Mailing Address - Street 1:PO BOX 62227
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79711-2227
Mailing Address - Country:US
Mailing Address - Phone:432-570-0373
Mailing Address - Fax:432-687-3143
Practice Address - Street 1:1030 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3149
Practice Address - Country:US
Practice Address - Phone:432-570-0373
Practice Address - Fax:432-687-3143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2869208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0895096-01Medicaid
TX180317300OtherDEPT OF LABOR
TX0895096-01Medicaid
TXE37365Medicare UPIN