Provider Demographics
NPI:1629163787
Name:DR. SUUSAN B. BETZER
Entity Type:Organization
Organization Name:DR. SUUSAN B. BETZER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:BETZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-823-0402
Mailing Address - Street 1:461 7TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4818
Mailing Address - Country:US
Mailing Address - Phone:727-823-0402
Mailing Address - Fax:727-823-4153
Practice Address - Street 1:461 7TH AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4818
Practice Address - Country:US
Practice Address - Phone:727-823-0402
Practice Address - Fax:727-823-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62235Medicare ID - Type Unspecified
FLD57358Medicare UPIN