Provider Demographics
NPI:1013102227
Name:GONNELLA, SUSAN LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNNE
Last Name:GONNELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 W 45TH ST FL 11
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4902
Mailing Address - Country:US
Mailing Address - Phone:866-271-3589
Mailing Address - Fax:315-692-0544
Practice Address - Street 1:25 W 45TH ST FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4902
Practice Address - Country:US
Practice Address - Phone:866-271-3589
Practice Address - Fax:315-692-0544
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176885207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT53903OtherNON-MEDICARE
PAMD453535OtherNON-MEDICARE
NY176885OtherLICENSE
NJ50870OtherNJ MEDICAL LICENSE
MI4301109059OtherNON-MEDICARE
ORMD174379OtherNON-MEDICARE
FLME122217OtherNON-MEDICARE
VA0101257922OtherNON-MEDICARE
CAC130434OtherCA MEDICAL LICENSE
MDD008371OtherNON-MEDICARE
DCMD043243OtherNON-MEDICARE
IL036.136110OtherNON-MEDICARE