Provider Demographics
NPI:1851452635
Name:DASTA, SUSAN LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LEE
Last Name:DASTA
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 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:245
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-246-5900
Mailing Address - Fax:816-332-6750
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:245
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-246-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002019232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200587160AMedicaid
KS200587160BMedicaid
MO208318808Medicaid
MO1851452635Medicaid
31636039OtherBLUECROSS BLUESHIELD OF KANSAS CITY
MO208318808Medicaid
KS200587160AMedicaid
31636039OtherBLUECROSS BLUESHIELD OF KANSAS CITY
MO1851452635Medicaid