Provider Demographics
NPI:1639249022
Name:DOBERNECK, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:DOBERNECK
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:PO BOX 21609
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89721-1609
Mailing Address - Country:US
Mailing Address - Phone:775-884-2455
Mailing Address - Fax:775-884-0345
Practice Address - Street 1:1600 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4625
Practice Address - Country:US
Practice Address - Phone:775-445-8502
Practice Address - Fax:775-888-4448
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7169207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1639249022Medicaid
NVF59582Medicare UPIN
NVV104211Medicare PIN