Provider Demographics
NPI:1255783270
Name:SUSANTO, KENNY (MD)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:SUSANTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S WHEELING AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 S WHEELING AVE STE 701
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5647
Practice Address - Country:US
Practice Address - Phone:918-748-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-02
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1.0650042084N0400X
GA0088632084N0400X
OK387942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology