Provider Demographics
NPI:1942209572
Name:BLAIR, SUSAN DIANE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:201 EXECUTIVE CT STE A
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4536
Mailing Address - Country:US
Mailing Address - Phone:501-224-5658
Mailing Address - Fax:501-223-8656
Practice Address - Street 1:4200 N RODNEY PARHAM RD STE 101
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-2458
Practice Address - Country:US
Practice Address - Phone:501-224-5658
Practice Address - Fax:501-224-8114
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2019-10-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARC7661207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR08-20033OtherUNITED HEALTHCARE
AR180030604OtherRAILROAD MEDICARE
AR5B955OtherBLUE CROSS PAY TO PROVIDE
AR4514242OtherAETNA
AR11825OtherCOORDINATED VISION CARE
AR13629000000OtherQUALCHOICE
AR54157OtherBLUE CROSS OF AR
ARCJ3133OtherRR MEDICARE GROUP #
AR2454752OtherCIGNA
AR125599001Medicaid
ARC7661OtherSTATE MEDICAL BOARD
ARC7661OtherSTATE MEDICAL BOARD
AR54157OtherBLUE CROSS OF AR
AR125599001Medicaid