Provider Demographics
NPI:1437126695
Name:VAN PELT, SUSAN G (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:VAN PELT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:952-857-1554
Practice Address - Street 1:303 CATLIN ST
Practice Address - Street 2:BUFFALO HOSPITAL
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313
Practice Address - Country:US
Practice Address - Phone:763-684-7500
Practice Address - Fax:763-684-7152
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN31741OtherMEDICAL LICENSE
MN305897200Medicaid
MN31741OtherMEDICAL LICENSE
F44159Medicare UPIN