Provider Demographics
NPI:1770589145
Name:HUSTAD, SUSAN C (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:HUSTAD
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 1:425 E 5350 S
Mailing Address - Street 2:STE 335
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6990
Mailing Address - Country:US
Mailing Address - Phone:801-475-8600
Mailing Address - Fax:801-475-8686
Practice Address - Street 1:425 E 5350 S
Practice Address - Street 2:STE 335
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6990
Practice Address - Country:US
Practice Address - Phone:801-475-8600
Practice Address - Fax:801-475-8686
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT377470-1205207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT377470-1205OtherPHYSICAN & SURGEON LICENS
UT377470-8905OtherSTATE CONTROLLED SUBSTANC
UTBH6894174OtherDEA #
UTBH6894174OtherDEA #
UTH34697Medicare UPIN
UTBH6894174OtherDEA #