Healthcare Provider Details

I. General information

NPI: 1982083606
Provider Name (Legal Business Name): MARK SUSSMAN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2926 WINTERS CHASE WAY
ANNAPOLIS MD
21401-7704
US

IV. Provider business mailing address

2926 WINTERS CHASE WAY
ANNAPOLIS MD
21401-7704
US

V. Phone/Fax

Practice location:
  • Phone: 410-266-9120
  • Fax: 443-949-0226
Mailing address:
  • Phone: 410-266-9120
  • Fax: 443-949-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00266
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number00266
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: