Provider Demographics
NPI:1013950955
Name:WALKER, SUSAN DIANA (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DIANA
Last Name:WALKER
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:600 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-2235
Practice Address - Country:US
Practice Address - Phone:631-638-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211855208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH27222Medicare UPIN
NY0B8541Medicare ID - Type Unspecified
NY7502256OtherAETNA
NY02105939Medicaid
NY268X51OtherEMPIRE BC.BS