Provider Demographics
NPI:1255397923
Name:NONDAHL, SUSAN R (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:NONDAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4410 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4901
Mailing Address - Country:US
Mailing Address - Phone:608-233-9746
Mailing Address - Fax:
Practice Address - Street 1:4410 REGENT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4901
Practice Address - Country:US
Practice Address - Phone:608-233-9746
Practice Address - Fax:608-233-0026
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24853-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30615600Medicaid
WIA02449Medicare UPIN
WI153950023Medicare ID - Type Unspecified