Provider Demographics
NPI:1649261710
Name:HART-CAVALLO, SUSAN R (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:HART-CAVALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:53800 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1543
Mailing Address - Country:US
Mailing Address - Phone:574-273-3880
Mailing Address - Fax:574-271-0918
Practice Address - Street 1:720 CEDAR ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2060
Practice Address - Country:US
Practice Address - Phone:574-232-3327
Practice Address - Fax:574-232-3369
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01055451A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200372550Medicaid
IN200372550Medicaid
IN146470KKKKMedicare ID - Type Unspecified