Provider Demographics
NPI:1518986827
Name:DEVINE, SUSAN ROBERTSON (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROBERTSON
Last Name:DEVINE
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 1:4403 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416
Mailing Address - Country:US
Mailing Address - Phone:806-791-1122
Mailing Address - Fax:806-791-2252
Practice Address - Street 1:4403 6TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416
Practice Address - Country:US
Practice Address - Phone:806-791-1122
Practice Address - Fax:806-791-2252
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX089807402Medicaid
TX089807402Medicaid
TXB107028Medicare PIN