Provider Demographics
NPI:1790076453
Name:WALSTRA, SUSAN ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANNE
Last Name:WALSTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4601 HEATHERWIND DR
Mailing Address - Street 2:APT. D
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7135
Mailing Address - Country:US
Mailing Address - Phone:260-420-1433
Mailing Address - Fax:260-745-3643
Practice Address - Street 1:4601 HEATHERWIND DR
Practice Address - Street 2:APT. D
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7135
Practice Address - Country:US
Practice Address - Phone:260-420-1433
Practice Address - Fax:260-745-3643
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034161A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist