Provider Demographics
NPI:1770555427
Name:VAN DE WATER, SUSAN DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DEAN
Last Name:VAN DE WATER
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 62227
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79711-2227
Mailing Address - Country:US
Mailing Address - Phone:432-570-0373
Mailing Address - Fax:432-687-3143
Practice Address - Street 1:1030 N GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-3149
Practice Address - Country:US
Practice Address - Phone:432-570-0373
Practice Address - Fax:432-687-3143
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2869208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0895096-01Medicaid
180317300OtherDEPT OF LABOR
180317300OtherDEPT OF LABOR
TXTXB106021Medicare PIN
TX00D83ZMedicare PIN