Provider Demographics
NPI:1639264807
Name:GHANI, SUSAN DENISE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DENISE
Last Name:GHANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DENISE
Other - Last Name:NEADEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:575 RIVERGATE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7487
Mailing Address - Country:US
Mailing Address - Phone:970-403-1340
Mailing Address - Fax:970-403-1341
Practice Address - Street 1:575 RIVERGATE UNIT 204
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7490
Practice Address - Country:US
Practice Address - Phone:970-403-1340
Practice Address - Fax:970-403-1341
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42057207R00000X
CAA75844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75385830Medicaid
CO75385830Medicaid
CO75385830Medicaid
H79957Medicare UPIN