Provider Demographics
NPI:1669050613
Name:COLLINS, SUSANA MARIE (MD)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:MARIE
Last Name:COLLINS
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3841
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:7926 PRESTON HWY STE 108
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3848
Practice Address - Country:US
Practice Address - Phone:502-964-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ILR5696208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program