Healthcare Provider Details

I. General information

NPI: 1043206568
Provider Name (Legal Business Name): SUSAN DAVIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FOUNDERS PLZ STE 400
EAST HARTFORD CT
06108-3240
US

IV. Provider business mailing address

111 FOUNDERS PLZ STE 400
EAST HARTFORD CT
06108-3240
US

V. Phone/Fax

Practice location:
  • Phone: 860-289-3375
  • Fax:
Mailing address:
  • Phone: 860-289-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number59103
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number59103
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number59103
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number59103
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number59103
License Number StateMA
# 6
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number59103
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: