Healthcare Provider Details

I. General information

NPI: 1124363098
Provider Name (Legal Business Name): SUSANNA C OH D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7031 SW 62ND AVE
SOUTH MIAMI FL
33143-4701
US

IV. Provider business mailing address

PO BOX 430374
MIAMI FL
33243-0374
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number20A11417
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberUO3396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: