Healthcare Provider Details

I. General information

NPI: 1821934209
Provider Name (Legal Business Name): SUSANA GLORIA COUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 N 4TH ST
BUCKEYE AZ
85326-2404
US

IV. Provider business mailing address

18455 N 167TH LN
SURPRISE AZ
85374-6857
US

V. Phone/Fax

Practice location:
  • Phone: 623-910-6033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number338295
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: