Provider Demographics
NPI:1568412310
Name:ANDERSON, SUSAN K (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:TAHLEQUAH MEDICAL GROUP
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0500
Mailing Address - Country:US
Mailing Address - Phone:918-456-0641
Mailing Address - Fax:918-453-2341
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4133
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057769207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200317560AMedicaid
GA454914001BMedicaid
GA454914001AMedicaid
GA04BDCRWOtherMEDICARE
SCG57769Medicaid
GA454914001BMedicaid
GA04BDCRWMedicare PIN
OKOKAAA0336Medicare PIN