Provider Demographics
NPI:1720076458
Name:ST PIERRE, SUSAN MARIE (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:ST PIERRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1615 HILL RD STE 14
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4304
Mailing Address - Country:US
Mailing Address - Phone:415-895-1441
Mailing Address - Fax:415-968-6620
Practice Address - Street 1:1615 HILL RD STE 14
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947
Practice Address - Country:US
Practice Address - Phone:415-895-1441
Practice Address - Fax:415-895-1288
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1409207Q00000X
CA20A14943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34330534Medicaid
AZ796386Medicaid
ME243530099Medicaid
CO48178845Medicaid
HBP16Medicare ID - Type Unspecified
AZ796386Medicaid
MEMM941301Medicare PIN