Provider Demographics
NPI:1396728812
Name:ESTRADA-TE, SUSAN V (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:V
Last Name:ESTRADA-TE
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 1:13 STONEY BROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125-7803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:239 EDGEWOOD DRIVE EXT
Practice Address - Street 2:
Practice Address - City:TRANSFER
Practice Address - State:PA
Practice Address - Zip Code:16154-1817
Practice Address - Country:US
Practice Address - Phone:724-589-6441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062293L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2502063Medicaid
PA0016769370007Medicaid
PA0016769370007Medicaid