Provider Demographics
NPI:1912960121
Name:SALEHI, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SALEHI
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 1:1518 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4511
Mailing Address - Country:US
Mailing Address - Phone:904-269-1661
Mailing Address - Fax:904-264-4085
Practice Address - Street 1:1518 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4511
Practice Address - Country:US
Practice Address - Phone:904-269-1661
Practice Address - Fax:904-264-4085
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46259174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61565Medicare UPIN
FL10079Medicare ID - Type Unspecified