Provider Demographics
NPI:1861457921
Name:RATHBUN, SUSAN G (DPM)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:G
Last Name:RATHBUN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97055-0067
Mailing Address - Country:US
Mailing Address - Phone:503-317-4911
Mailing Address - Fax:
Practice Address - Street 1:10948 SE BOISE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:503-317-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00161213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT68036Medicare UPIN
ORR0000SGBGJMedicare ID - Type Unspecified