Provider Demographics
NPI:1972569333
Name:GALVIN, SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GALVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:CATHERINE
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-560-2900
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:4040 N MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE A
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-644-4673
Practice Address - Fax:702-902-5443
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14531207Q00000X
VA0101225470207Q00000X
OH35089384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1972569333Medicaid
NVGU728ZMedicare PIN