1063440105 NPI number — DR. MICHAEL VITTORIO SUSANO M.D.

Table of content: ERIN M TESTA LCSW, LCDP (NPI 1437440500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063440105 NPI number — DR. MICHAEL VITTORIO SUSANO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUSANO
Provider First Name:
MICHAEL
Provider Middle Name:
VITTORIO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063440105
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 MEDICAL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SULPHUR SPRINGS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75482-2138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-869-2044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 N HEARNE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71107-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-676-5111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  025874 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1041840 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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