Provider Demographics
NPI:1619924735
Name:CRUSE, SUSAN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:CRUSE
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 1:5450 WESTERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-8820
Mailing Address - Fax:303-938-3499
Practice Address - Street 1:101 ERIE PKWY STE 201E
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:CO
Practice Address - Zip Code:80516-4072
Practice Address - Country:US
Practice Address - Phone:303-415-8820
Practice Address - Fax:303-938-3499
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45815207R00000X
TXK8100207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46473734Medicaid
CO46473734Medicaid
H26554Medicare UPIN
COC810722Medicare PIN