Provider Demographics
NPI:1982778635
Name:SUSKI, EDMUND THADDEUS (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:THADDEUS
Last Name:SUSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 WOODLAND ST
Mailing Address - Street 2:SUITE 44
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-247-2169
Mailing Address - Fax:860-247-8093
Practice Address - Street 1:19 WOODLAND ST
Practice Address - Street 2:SUITE 44
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-247-2169
Practice Address - Fax:860-247-8093
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022090207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001220904Medicare ID - Type Unspecified
B83149Medicare UPIN
180000243Medicare ID - Type Unspecified