Provider Demographics
NPI:1821231408
Name:STEIN, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BRUCKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:541-768-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR157881208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics