Provider Demographics
NPI:1578588893
Name:SMITH, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:SMITH
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:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-7719
Mailing Address - Fax:
Practice Address - Street 1:4451 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2601
Practice Address - Country:US
Practice Address - Phone:850-416-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051557666Medicare ID - Type Unspecified
ALG17711Medicare UPIN
AL000072909Medicaid
AL51072909OtherBC SWEETWATER LOCATION
AL51532830OtherBC HOSPITAL DR LOCATION
AL000072909Medicare ID - Type Unspecified