Provider Demographics
NPI:1295345783
Name:SHOTTS, SUSAN (RT (R))
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SHOTTS
Suffix:
Gender:F
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S 107TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-5703
Mailing Address - Country:US
Mailing Address - Phone:484-272-4239
Mailing Address - Fax:
Practice Address - Street 1:861 N HIGLEY RD STE B101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-9602
Practice Address - Country:US
Practice Address - Phone:480-813-9600
Practice Address - Fax:480-813-9601
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRT182362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCRT18236OtherSTATE F AZ LICENSE