Provider Demographics
NPI:1295711711
Name:SUSMAN, JEFFREY LOUIS (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LOUIS
Last Name:SUSMAN
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 1:2830 VICTORY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1786
Mailing Address - Country:US
Mailing Address - Phone:513-245-3052
Mailing Address - Fax:
Practice Address - Street 1:305 CRESCENT AVENUE
Practice Address - Street 2:UNIVERSITY WYOMING FAMILY PRACTICE CENTER
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215
Practice Address - Country:US
Practice Address - Phone:513-821-0275
Practice Address - Fax:513-821-3621
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.077346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2163135Medicaid
OHSU7363811Medicare PIN
B90910Medicare UPIN
OH2163135Medicaid
SU0892322Medicare ID - Type Unspecified
OHSU4238511Medicare PIN
OHSU0892328Medicare PIN