Provider Demographics
NPI:1700871803
Name:DENMAN, SUSAN TOBEY (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:TOBEY
Last Name:DENMAN
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 1:4546 SW HUMPHREY BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18345 SW ALEXANDER ST
Practice Address - Street 2:SUITE B
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-3960
Practice Address - Country:US
Practice Address - Phone:503-649-9477
Practice Address - Fax:503-649-1272
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12671207N00000X, 207NS0135X, 207NP0225X, 207ND0900X, 207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
38D0621698OtherCLIA
070002027OtherRAILROAD MEDICARE
048142000OtherREGENCE BLUE CROSS BLUE SHIELD OF OREGON
OR260760Medicaid
OR260760Medicaid
38D0621698OtherCLIA