Provider Demographics
NPI:1619993938
Name:CRISWELL, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:CRISWELL
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 1:240 W THOMAS RD # 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4407
Mailing Address - Country:US
Mailing Address - Phone:602-406-6262
Mailing Address - Fax:602-406-6261
Practice Address - Street 1:240 W THOMAS RD # 301
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4407
Practice Address - Country:US
Practice Address - Phone:602-406-6262
Practice Address - Fax:602-406-6261
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050227132084N0400X
AZ673202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ149894Medicaid
MO207231200Medicaid
MO935310101Medicare PIN
IL$$$$$$$$$Medicaid