Provider Demographics
NPI:1578540431
Name:BLUE, SUSAN KELLY (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KELLY
Last Name:BLUE
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 1:1001 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3049
Mailing Address - Country:US
Mailing Address - Phone:817-334-7922
Mailing Address - Fax:817-870-2144
Practice Address - Street 1:1001 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3049
Practice Address - Country:US
Practice Address - Phone:817-334-7922
Practice Address - Fax:817-870-2144
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1506174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist