Provider Demographics
NPI:1922079862
Name:SUSI, BRIAN DIEVENDORF (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DIEVENDORF
Last Name:SUSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 JEFFERSON ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2606
Mailing Address - Country:US
Mailing Address - Phone:917-232-2458
Mailing Address - Fax:
Practice Address - Street 1:411 JEFFERSON ST
Practice Address - Street 2:UNIT 2
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-2606
Practice Address - Country:US
Practice Address - Phone:917-232-2458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09314200207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease