Provider Demographics
NPI:1629034699
Name:O'CONNOR, SUSAN E (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:O'CONNOR
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 1:33 WHITING HILL RD
Mailing Address - Street 2:SUITE 33
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1021
Mailing Address - Country:US
Mailing Address - Phone:207-973-9720
Mailing Address - Fax:207-973-9710
Practice Address - Street 1:33 WHITING HILL RD
Practice Address - Street 2:SUITE 33
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1021
Practice Address - Country:US
Practice Address - Phone:207-973-9720
Practice Address - Fax:207-973-9710
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013812174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME296670099Medicaid
ME296670099Medicaid
MEMM5487Medicare ID - Type Unspecified