Provider Demographics
NPI:1497754295
Name:PERRY, SUSAN BARBARA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BARBARA
Last Name:PERRY
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 1:2535 MAPLECREST RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-7709
Mailing Address - Country:US
Mailing Address - Phone:563-332-1500
Mailing Address - Fax:563-332-1005
Practice Address - Street 1:2535 MAPLECREST RD
Practice Address - Street 2:SUITE 20
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-7709
Practice Address - Country:US
Practice Address - Phone:563-332-1500
Practice Address - Fax:563-332-1005
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24610207N00000X
IA4301044740207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA22233OtherWELLMARK BCBS
IA0222331Medicaid
IA22233Medicare ID - Type Unspecified
IA22233OtherWELLMARK BCBS