Provider Demographics
NPI:1851329825
Name:SUSTERSIC, VINCENT P (DO)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:P
Last Name:SUSTERSIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 HIDDEN CANYON DR
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5901 E ROYALTON RD STE 2600
Practice Address - Street 2:
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-3532
Practice Address - Country:US
Practice Address - Phone:216-524-8883
Practice Address - Fax:216-524-2125
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5058249Medicaid
OH5058249Medicaid
OHSUO0525161Medicare ID - Type Unspecified