Provider Demographics
NPI:1336360254
Name:OTT HEASLEY, SUSAN DIANE (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:OTT HEASLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 N WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1197
Mailing Address - Country:US
Mailing Address - Phone:620-669-2500
Mailing Address - Fax:316-540-6193
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:KS
Practice Address - Zip Code:67025-8844
Practice Address - Country:US
Practice Address - Phone:620-259-6221
Practice Address - Fax:316-540-6193
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020340207Q00000X
KS6554207R00000X
KS05-45046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MO1336360254Medicaid
MOP00985977OtherRR MCR
MO1336360254Medicaid