Provider Demographics
NPI:1982666426
Name:SUSSMAN, EUGENE KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:KENNETH
Last Name:SUSSMAN
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 1:21 PEBBLE RIDGE COURT
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854
Mailing Address - Country:US
Mailing Address - Phone:240-361-8844
Mailing Address - Fax:240-715-9636
Practice Address - Street 1:21 PEBBLE RIDGE COURT
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854
Practice Address - Country:US
Practice Address - Phone:240-361-8844
Practice Address - Fax:240-715-9636
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00015927208000000X
MDD15927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB94444Medicare UPIN