Provider Demographics
NPI:1588603179
Name:SUSINI, LAURENCE M (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:M
Last Name:SUSINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL
Mailing Address - Street 2:#100
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-458-6088
Mailing Address - Fax:520-458-3983
Practice Address - Street 1:155 CALLE PORTAL
Practice Address - Street 2:#100
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-458-6088
Practice Address - Fax:520-458-3983
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17611207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ284985Medicaid
AZ0779560OtherBCBS AZ
2Z2281OtherHEALTH NET
AZ284985Medicaid
104398Medicare ID - Type Unspecified