Provider Demographics
NPI:1871670638
Name:BOCKENHAUER, SUSAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:BOCKENHAUER
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 1:225 LINCOLN PL
Mailing Address - Street 2:APT. # 6-F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3746
Mailing Address - Country:US
Mailing Address - Phone:646-872-9819
Mailing Address - Fax:
Practice Address - Street 1:96 5TH AVE
Practice Address - Street 2:SUITE # 1-L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-7605
Practice Address - Country:US
Practice Address - Phone:646-872-9819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG86245Medicare UPIN
NY9X4102Medicare ID - Type Unspecified