Provider Demographics
NPI:1497781595
Name:GELETKA, SUSAN MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARY
Last Name:GELETKA
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 1:9275 W CALLA RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9459
Mailing Address - Country:US
Mailing Address - Phone:330-533-2775
Mailing Address - Fax:
Practice Address - Street 1:9275 W CALLA RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9459
Practice Address - Country:US
Practice Address - Phone:330-533-2775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2013-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031019E2085R0202X
OH35.0495842085R0202X
IN01047749A2085R0202X
MI43010713512085R0202X
NH108362085R0202X
IL036-1048912085R0202X
NY168054-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001534109Medicaid
OH0561673Medicaid
OH0561673Medicaid
F90958Medicare UPIN