Provider Demographics
NPI:1437158896
Name:ROBERTS, SUSAN (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26028
Mailing Address - Street 2:CLINICIAN SERVICES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-237-8700
Mailing Address - Fax:505-237-8703
Practice Address - Street 1:2050A 2ND ST SE
Practice Address - Street 2:
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5522
Practice Address - Country:US
Practice Address - Phone:505-846-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2574207Q00000X
NMA-1723-13207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153862101Medicaid
NM00002166Medicaid
TX8316B6Medicare PIN
TXG57486Medicare UPIN