Provider Demographics
NPI:1578520227
Name:LASSIEUR ROBERTSON, SUSANNE L (MD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:L
Last Name:LASSIEUR ROBERTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:MARIE
Other - Last Name:LASSIEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023
Mailing Address - Country:US
Mailing Address - Phone:501-843-4555
Mailing Address - Fax:501-843-7081
Practice Address - Street 1:2037 WEST MAIN
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023
Practice Address - Country:US
Practice Address - Phone:501-843-4555
Practice Address - Fax:501-843-7081
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2127207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H51564Medicare UPIN
5M050Medicare ID - Type Unspecified