Provider Demographics
NPI:1508824053
Name:PORTER, SUSAN ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:PORTER
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 1:6777 ENGLE RD
Mailing Address - Street 2:STE N
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-7941
Mailing Address - Country:US
Mailing Address - Phone:440-627-2040
Mailing Address - Fax:770-237-1627
Practice Address - Street 1:6777 ENGLE RD
Practice Address - Street 2:STE N
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-7941
Practice Address - Country:US
Practice Address - Phone:440-627-2040
Practice Address - Fax:770-237-1627
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081245207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2576798Medicaid
OH2576798Medicaid
I28980Medicare UPIN