Provider Demographics
NPI:1568435634
Name:CLANZY, SUSAN RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:RENEE
Last Name:CLANZY
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 1:310 N EUTAW ST
Mailing Address - Street 2:SUITE 3307
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1807
Mailing Address - Country:US
Mailing Address - Phone:410-446-2257
Mailing Address - Fax:301-596-4716
Practice Address - Street 1:310 N EUTAW ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1807
Practice Address - Country:US
Practice Address - Phone:410-446-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060902208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD3364208 00Medicaid