Provider Demographics
NPI:1265403760
Name:VETTICHIRA, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:VETTICHIRA
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 1:147 HWY 24
Mailing Address - Street 2:HESTRON PLAZA, SUITE 102
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-8998
Mailing Address - Country:US
Mailing Address - Phone:252-726-4000
Mailing Address - Fax:252-726-2530
Practice Address - Street 1:147 HIGHWAY 24
Practice Address - Street 2:HESTRON PLAZA, SUITE 102
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4306
Practice Address - Country:US
Practice Address - Phone:252-726-4000
Practice Address - Fax:252-726-2530
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85242208100000X
NC2008-01112208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
H74541Medicare UPIN
NC2022871Medicare PIN
FLH74541Medicare UPIN
FL62083ZMedicare ID - Type Unspecified