Provider Demographics
NPI:1891050134
Name:SUSIE-LATTNER, DEBRA DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:DIANE
Last Name:SUSIE-LATTNER
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 1:801 S MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-3204
Mailing Address - Country:US
Mailing Address - Phone:847-990-2125
Mailing Address - Fax:847-362-8031
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-990-2125
Practice Address - Fax:847-362-8031
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-071098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine