Provider Demographics
NPI:1760443691
Name:SUSCO, MICHELLE S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:S
Last Name:SUSCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1830 TOWN CENTER DR
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3292
Mailing Address - Country:US
Mailing Address - Phone:703-435-3636
Mailing Address - Fax:703-435-9145
Practice Address - Street 1:1830 TOWN CENTER DR
Practice Address - Street 2:SUITE # 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3292
Practice Address - Country:US
Practice Address - Phone:703-435-3636
Practice Address - Fax:703-435-9145
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2008-06-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101050668208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6709508Medicaid
VAG30957Medicare UPIN