Provider Demographics
NPI:1487834206
Name:DEPAULO, SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:
Last Name:DEPAULO
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 1:2417 OAKGROVE CIR
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225-1447
Mailing Address - Country:US
Mailing Address - Phone:787-720-5956
Mailing Address - Fax:
Practice Address - Street 1:1190 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7358
Practice Address - Country:US
Practice Address - Phone:314-286-6988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0053278207Q00000X
IN01064693A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine