Provider Demographics
NPI:1578556387
Name:MALANE, SUSAN LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:MALANE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 S MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5322
Mailing Address - Country:US
Mailing Address - Phone:813-685-7714
Mailing Address - Fax:813-685-0113
Practice Address - Street 1:116 S MONTCLAIR AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5322
Practice Address - Country:US
Practice Address - Phone:813-685-7714
Practice Address - Fax:813-685-0113
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7746207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH54561Medicare UPIN
FL06582YMedicare ID - Type Unspecified