Provider Demographics
NPI:1629047089
Name:DVERGSTEN, SUZANNE ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:DVERGSTEN
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 1:1234 HUFFMAN MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8700
Mailing Address - Country:US
Mailing Address - Phone:336-538-1234
Mailing Address - Fax:336-584-5811
Practice Address - Street 1:908 SOUTH WILLIAMSON AVENUE
Practice Address - Street 2:
Practice Address - City:ELON
Practice Address - State:NC
Practice Address - Zip Code:27244
Practice Address - Country:US
Practice Address - Phone:336-538-2516
Practice Address - Fax:336-584-6811
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2101-01891208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN50456700Medicaid
MN50456700Medicaid
F62128Medicare UPIN