Provider Demographics
NPI:1790781078
Name:BURROUGHS, SUSAN F (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:F
Last Name:BURROUGHS
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 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:
Practice Address - Street 1:400 TALCOTTVILLE RD # 1
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4051
Practice Address - Country:US
Practice Address - Phone:860-896-4718
Practice Address - Fax:860-896-1426
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030948207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001309485Medicaid
CTE66384Medicare UPIN
CT001309485Medicaid