Provider Demographics
NPI:1740370071
Name:LOVE, SUSAN G (DPM)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:LOVE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-5002
Mailing Address - Country:US
Mailing Address - Phone:321-267-5577
Mailing Address - Fax:321-264-0724
Practice Address - Street 1:1717 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-5002
Practice Address - Country:US
Practice Address - Phone:321-267-5577
Practice Address - Fax:321-264-0724
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5DZKSOtherFLORIDA BLUE IDENTIFICATION NUMBER
FL1720451446OtherGROUP NPI
FLIB417YMedicare PIN
NYT32204Medicare UPIN
NY98378GMedicare PIN