Provider Demographics
NPI:1508893975
Name:WHITMORE, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WHITMORE
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 1:13943 N 91ST AVE
Mailing Address - Street 2:C-101
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3629
Mailing Address - Country:US
Mailing Address - Phone:623-760-9449
Mailing Address - Fax:623-974-9351
Practice Address - Street 1:14506 W GRANITE VALLEY DR
Practice Address - Street 2:#124
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-6010
Practice Address - Country:US
Practice Address - Phone:623-584-2127
Practice Address - Fax:623-584-1257
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43436207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00942249OtherRAILROAD MEDICARE
AZ5496138OtherAETNA
AZ757814OtherARIZONA MEDICAL NETWORK
AZ1458299OtherUNITED HEALTHCARE
MD285731600Medicaid
AZ618847OtherAHCCCS
AZ1508893975OtherBLUE CROSS BLUE SHIELD
AZ618847Medicaid
AZ618847Medicaid
AZ145278Medicare PIN
AZ618847Medicaid