Provider Demographics
NPI:1558926675
Name:SUSI, THOMAS TONY JR
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:TONY
Last Name:SUSI
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 LINTON RD
Mailing Address - Street 2:
Mailing Address - City:PONCE DE LEON
Mailing Address - State:FL
Mailing Address - Zip Code:32455-3732
Mailing Address - Country:US
Mailing Address - Phone:850-428-3570
Mailing Address - Fax:
Practice Address - Street 1:225 E ROBINSON ST STE 220
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-4368
Practice Address - Country:US
Practice Address - Phone:407-380-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9302252163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty