Provider Demographics
NPI:1619918042
Name:BRULTE, SUZANNE MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:MITCHELL
Last Name:BRULTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3839 COUNTY ROAD 218
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-5708
Mailing Address - Country:US
Mailing Address - Phone:904-379-7155
Mailing Address - Fax:904-379-7165
Practice Address - Street 1:14011 BEACH BLVD
Practice Address - Street 2:UNIT 120
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1694
Practice Address - Country:US
Practice Address - Phone:904-223-6400
Practice Address - Fax:904-223-6420
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89658207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0042847-00Medicaid
FLFN075ZMedicare PIN
FLFN075ZMedicare PIN