Provider Demographics
NPI:1013905363
Name:POWELL, SUZANNE M (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:POWELL
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 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-963-6390
Mailing Address - Fax:860-963-6343
Practice Address - Street 1:12A LEDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1690
Practice Address - Country:US
Practice Address - Phone:860-423-2960
Practice Address - Fax:860-423-3719
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT042791208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001427914Medicaid
G27707Medicare UPIN
CT370001565Medicare ID - Type Unspecified