Healthcare Provider Details

I. General information

NPI: 1487834206
Provider Name (Legal Business Name): SUZANNE DEPAULO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 FORTUNE BLVD
SHILOH IL
62269-7358
US

IV. Provider business mailing address

2417 OAKGROVE CIR
SCOTT AFB IL
62225-1447
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-6988
  • Fax:
Mailing address:
  • Phone: 787-720-5956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0053278
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: