Provider Demographics
NPI:1891016390
Name:STONE, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:STONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 SPRINGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9678
Mailing Address - Country:US
Mailing Address - Phone:315-481-2551
Mailing Address - Fax:
Practice Address - Street 1:600 E GENESEE ST STE 114
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3108
Practice Address - Country:US
Practice Address - Phone:315-758-2683
Practice Address - Fax:315-517-8116
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102921207Q00000X
390200000X
NY295689207Q00000X
CAA131126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program