Provider Demographics
NPI:1457359598
Name:NASRI, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:NASRI
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 1:2914 S REPUBLIC BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-1912
Mailing Address - Country:US
Mailing Address - Phone:419-531-8808
Mailing Address - Fax:419-531-9342
Practice Address - Street 1:5734 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7141
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:260-432-9812
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052481207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN050087310OtherRAILROAD MEDICARE
IN200357570Medicaid
IN163856OtherCSHCS
IN163855OtherCSHCS
IN163857OtherCSHCS
IN163857OtherCSHCS
IN189170HMedicare ID - Type UnspecifiedINDIANA MEDICARE