Provider Demographics
NPI:1295812725
Name:YANG, SUSAN WILSON (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:WILSON
Last Name:YANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:G
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-543-5942
Mailing Address - Fax:314-543-5947
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:SUITE 200/220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-543-5942
Practice Address - Fax:314-543-5947
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156440016OtherMEDICARE PTAN
MOH30208Medicare UPIN