Provider Demographics
NPI:1205889920
Name:WOLTANSKI, SUZANNE (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:WOLTANSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:KINGERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:29130 RIVERBANK ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-1633
Mailing Address - Country:US
Mailing Address - Phone:586-463-7432
Mailing Address - Fax:
Practice Address - Street 1:13355 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:586-759-7510
Practice Address - Fax:586-759-7791
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059819208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4609286Medicaid
MI4609286Medicaid