Provider Demographics
NPI:1265412662
Name:PAULSON, SUSAN D (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:PAULSON
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 1:3905 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3391
Mailing Address - Country:US
Mailing Address - Phone:320-763-4135
Mailing Address - Fax:866-431-0804
Practice Address - Street 1:3905 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3391
Practice Address - Country:US
Practice Address - Phone:320-763-4135
Practice Address - Fax:866-431-0804
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN492267100Medicaid
MN080050456OtherRR MEDICARE
MN080022717Medicare PIN
MN492267100Medicaid
MN6697670002Medicare NSC