Provider Demographics
NPI:1972536878
Name:START, SUSAN JO (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JO
Last Name:START
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JO
Other - Last Name:DEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1808
Mailing Address - Country:US
Mailing Address - Phone:803-328-6281
Mailing Address - Fax:803-981-5136
Practice Address - Street 1:1698 HIGHWAY 160 W
Practice Address - Street 2:SUITE 220
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-8032
Practice Address - Country:US
Practice Address - Phone:803-802-5900
Practice Address - Fax:803-802-7101
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22022208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC220228Medicaid
NC067TPOtherBC/BS