Provider Demographics
NPI:1578542668
Name:TEGGATZ, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:TEGGATZ
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 1:5409 AVENUE O
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA33739208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1578542668OtherWELLMARK BLUE CROSS BLUE SHIELD
IA1578542668Medicaid
IAI11826Medicare ID - Type Unspecified
IA1578542668OtherWELLMARK BLUE CROSS BLUE SHIELD
IA1578542668Medicaid