Provider Demographics
NPI:1760697940
Name:O'LEARY, SUSAN LANE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LANE
Last Name:O'LEARY
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:PO BOX 4390
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-4390
Mailing Address - Country:US
Mailing Address - Phone:775-445-7650
Mailing Address - Fax:775-882-4206
Practice Address - Street 1:1470 MEDICAL PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4648
Practice Address - Country:US
Practice Address - Phone:775-445-7650
Practice Address - Fax:775-882-4206
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12741207RC0000X
CAA105681207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760697940Medicaid
NVAN974WMedicare PIN