Provider Demographics
NPI:1821356601
Name:SUSORENY-VELGOS, JENNIFER ELLEN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:SUSORENY-VELGOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 STATE AVE STE 108B
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4539
Mailing Address - Country:US
Mailing Address - Phone:850-252-7512
Mailing Address - Fax:
Practice Address - Street 1:2202 STATE AVE STE 108B
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4539
Practice Address - Country:US
Practice Address - Phone:850-252-7512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-10631208600000X
FLOS-18050208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR221624003Medicaid