Provider Demographics
NPI:1477506053
Name:HUBELE, SUZANNA DYANN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNA
Middle Name:DYANN
Last Name:HUBELE
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:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-0871
Mailing Address - Country:US
Mailing Address - Phone:208-549-0211
Mailing Address - Fax:208-549-0104
Practice Address - Street 1:683 E 3RD ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2248
Practice Address - Country:US
Practice Address - Phone:208-549-0211
Practice Address - Fax:208-549-0104
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806904200Medicaid
IDOTH000Medicare UPIN
ID1477506053Medicare PIN
ID806904200Medicaid