Provider Demographics
NPI:1720205347
Name:SUSON, EDUARDO M (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:M
Last Name:SUSON
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 1:3110 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1210
Mailing Address - Country:US
Mailing Address - Phone:304-347-1300
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302
Practice Address - Country:US
Practice Address - Phone:304-347-1296
Practice Address - Fax:304-293-6963
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10971208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0127803000Medicaid
D49241Medicare UPIN
WVSU6035611Medicare PIN