Provider Demographics
NPI:1659604510
Name:SUSSMAN, EDWARD BART (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:BART
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COVE ROAD STUDIO
Mailing Address - Street 2:
Mailing Address - City:CHILMARK
Mailing Address - State:MA
Mailing Address - Zip Code:02535-0308
Mailing Address - Country:US
Mailing Address - Phone:508-645-3005
Mailing Address - Fax:508-645-2250
Practice Address - Street 1:3 COVE ROAD STUDIO
Practice Address - Street 2:
Practice Address - City:CHILMARK
Practice Address - State:MA
Practice Address - Zip Code:02535-0308
Practice Address - Country:US
Practice Address - Phone:508-645-3005
Practice Address - Fax:508-645-2250
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39001207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology