Provider Demographics
NPI:1700036654
Name:SOBOROFF, SUSAN BEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BEITH
Last Name:SOBOROFF
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 1:220 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3306
Mailing Address - Country:US
Mailing Address - Phone:607-330-1254
Mailing Address - Fax:
Practice Address - Street 1:220 S FULTON ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3306
Practice Address - Country:US
Practice Address - Phone:607-330-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD78431Medicare UPIN