Provider Demographics
NPI:1417045964
Name:SUSCO, THOMAS MARK II (DPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MARK
Last Name:SUSCO
Suffix:II
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 CAMERON RIDGE DR
Mailing Address - Street 2:APT 134
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-7668
Mailing Address - Country:US
Mailing Address - Phone:765-412-5469
Mailing Address - Fax:
Practice Address - Street 1:5949 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4348
Practice Address - Country:US
Practice Address - Phone:317-247-1579
Practice Address - Fax:317-247-1612
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009067A225100000X
IN36001336A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer