Provider Demographics
NPI:1912011222
Name:FLAGEL, SUSAN D (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:D
Last Name:FLAGEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:D
Other - Last Name:BURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:2572 COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34289-9356
Practice Address - Country:US
Practice Address - Phone:941-429-3545
Practice Address - Fax:941-429-3546
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3757208000000X
NE381208000000X
FLOS 10992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIK203YOtherMEDICARE
IA32137OtherWELLMARK BLUE SHIELD
IA1579250Medicaid
FL021026500Medicaid
IA0579250Medicaid
IA27579OtherWELLMARK BLUE SHIELD
FL149Q6OtherBCBS