Provider Demographics
NPI:1518075357
Name:LASEK-NESSELQUIST, SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:LASEK-NESSELQUIST
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:P.O. BOX 4767
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4767
Mailing Address - Country:US
Mailing Address - Phone:713-526-5511
Mailing Address - Fax:713-520-4755
Practice Address - Street 1:1701 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1713
Practice Address - Country:US
Practice Address - Phone:713-526-5511
Practice Address - Fax:713-520-4755
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2619207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BV154OtherBLUE CROSS BLUE SHIELD OF TEXAS
TXP00744698OtherMEDICARE RAILROAD PIN
TX8BV154OtherBLUE CROSS BLUE SHIELD OF TEXAS