Healthcare Provider Details

I. General information

NPI: 1386638864
Provider Name (Legal Business Name): SUSANNA O BUCHHOLZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 MACK BAYOU LOOP
SANTA ROSA BEACH FL
32459-2604
US

IV. Provider business mailing address

91 MACK BAYOU LOOP
SANTA ROSA BEACH FL
32459-2604
US

V. Phone/Fax

Practice location:
  • Phone: 850-659-6556
  • Fax:
Mailing address:
  • Phone: 850-659-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME90657
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: