Provider Demographics
NPI:1477963270
Name:WCISLAK, SUSAN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WCISLAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2409
Mailing Address - Fax:970-490-4155
Practice Address - Street 1:2121 E HARMONY RD STE 2200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-482-6456
Practice Address - Fax:970-482-3921
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.135605208600000X
AZ60454208600000X
CODR.0071443208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty