Provider Demographics
NPI:1578670089
Name:MOORE, SUSAN ELISABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELISABETH
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELISABETH
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 W GLEN ST
Mailing Address - Street 2:
Mailing Address - City:CRANDON
Mailing Address - State:WI
Mailing Address - Zip Code:54520-1355
Mailing Address - Country:US
Mailing Address - Phone:715-478-3318
Mailing Address - Fax:715-478-3255
Practice Address - Street 1:400 W GLEN ST
Practice Address - Street 2:
Practice Address - City:CRANDON
Practice Address - State:WI
Practice Address - Zip Code:54520-1355
Practice Address - Country:US
Practice Address - Phone:715-478-3318
Practice Address - Fax:715-478-3255
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine