Provider Demographics
NPI:1598750366
Name:JOLLY, SUSAN LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:JOLLY DYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1210 N. KENTUCKY
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775
Mailing Address - Country:US
Mailing Address - Phone:417-256-1745
Mailing Address - Fax:417-256-1746
Practice Address - Street 1:1210 N. KENTUCKY
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775
Practice Address - Country:US
Practice Address - Phone:417-256-1745
Practice Address - Fax:417-256-1746
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29220174400000X, 207X00000X
MO2015013479207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015013479OtherMISSOURI MEDICAL LICENSE
CO01292200Medicaid
CO29220OtherLICENSE
CO29220OtherLICENSE
MO2015013479OtherMISSOURI MEDICAL LICENSE
COA17035Medicare UPIN