Provider Demographics
NPI:1417375221
Name:ROEWE, SUSAN LIGHT (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LIGHT
Last Name:ROEWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1690 ELM ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-3679
Mailing Address - Country:US
Mailing Address - Phone:636-902-8505
Mailing Address - Fax:635-578-4885
Practice Address - Street 1:1690 ELM ST STE 300
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-3679
Practice Address - Country:US
Practice Address - Phone:563-690-2850
Practice Address - Fax:563-557-8488
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64848-20208000000X
IAMD-46764208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417375221Medicaid