Provider Demographics
NPI:1912015355
Name:LACKS, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LACKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2141 K STREET NW
Mailing Address - Street 2:SUITE 407
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1810
Mailing Address - Country:US
Mailing Address - Phone:202-293-8815
Mailing Address - Fax:202-293-4118
Practice Address - Street 1:2141 K STREET NW
Practice Address - Street 2:SUITE 407
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-1810
Practice Address - Country:US
Practice Address - Phone:202-293-8815
Practice Address - Fax:202-293-4118
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DC13189207RR0500X, 207RM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93388Medicare UPIN