Provider Demographics
NPI:1548219157
Name:THERRIAULT, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:THERRIAULT
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 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4411
Mailing Address - Country:US
Mailing Address - Phone:603-569-7574
Mailing Address - Fax:603-569-7582
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4411
Practice Address - Country:US
Practice Address - Phone:603-569-7574
Practice Address - Fax:603-569-7582
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3084294Medicaid
RE306802OtherMEDICARE PTAN
RE306802OtherMEDICARE PTAN