Provider Demographics
NPI:1417985623
Name:HIRTZ, SUSAN KATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHLEEN
Last Name:HIRTZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:S. KATHLEEN
Other - Middle Name:
Other - Last Name:HIRTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5720 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-5925
Mailing Address - Country:US
Mailing Address - Phone:352-633-3060
Mailing Address - Fax:352-633-3090
Practice Address - Street 1:5720 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-5925
Practice Address - Country:US
Practice Address - Phone:352-633-3060
Practice Address - Fax:352-633-3090
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14264207QA0505X
FLME0103996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1755OtherSAIF
OR117226Medicaid
ORA156501OtherPACIFICSOURCE PROVIDER ID
OR033467000OtherBLUE CROSS PROVIDER ID
OR033467000OtherBLUE CROSS PROVIDER ID
ORR0000BHTLDMedicare PIN
OR1755OtherSAIF