Provider Demographics
NPI:1962461970
Name:JANNOU, SUSAN C
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:JANNOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 TAMIAMI TRL N
Mailing Address - Street 2:SUITE A
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-3475
Mailing Address - Country:US
Mailing Address - Phone:941-966-1777
Mailing Address - Fax:941-966-8628
Practice Address - Street 1:2420 TAMIAMI TRL N
Practice Address - Street 2:SUITE A
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-3475
Practice Address - Country:US
Practice Address - Phone:941-966-1777
Practice Address - Fax:941-966-8628
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2384213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6201051OtherGHI
FL82277789OtherAARP
480028734OtherRAIL ROAD MEDICARE
FL65353OtherBLUECROSS BLUESHIELD
FL650951406OtherCHAMPUS
FL65353AMedicare PIN
FL82277789OtherAARP
FL1286650001Medicare NSC