Provider Demographics
NPI:1568723583
Name:SUSAN, PAOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:PAOLA
Middle Name:
Last Name:SUSAN
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 1:4025 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3726
Mailing Address - Country:US
Mailing Address - Phone:773-275-7700
Mailing Address - Fax:
Practice Address - Street 1:4025 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-3726
Practice Address - Country:US
Practice Address - Phone:773-275-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-136208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine