Healthcare Provider Details

I. General information

NPI: 1154340966
Provider Name (Legal Business Name): SUSAN M. FUDGE-ERICKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 LUTHERAN PARKWAY SUITE 200
WHEAT RIDGE CO
80033-6027
US

IV. Provider business mailing address

3555 LUTHERAN PARKWAY SUITE 200
WHEAT RIDGE CO
80033-6027
US

V. Phone/Fax

Practice location:
  • Phone: 720-284-3700
  • Fax: 303-467-0525
Mailing address:
  • Phone: 720-284-3700
  • Fax: 303-467-0525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34593
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01345933
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: