Provider Demographics
NPI:1669493904
Name:VITALIS, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:VITALIS
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 1:665 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1108
Mailing Address - Country:US
Mailing Address - Phone:218-347-1200
Mailing Address - Fax:218-346-4043
Practice Address - Street 1:737 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-4811
Practice Address - Fax:701-234-6979
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine