Provider Demographics
NPI:1750463980
Name:O'TOOLE-EVANS, SUSAN BAUER (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BAUER
Last Name:O'TOOLE-EVANS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:400 AVENUE K SE STE 6
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4123
Practice Address - Country:US
Practice Address - Phone:863-299-4567
Practice Address - Fax:863-297-9750
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57743174400000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME57743OtherMEDICAL LICENSE NUMBER
FL063869200Medicaid