Healthcare Provider Details

I. General information

NPI: 1366427940
Provider Name (Legal Business Name): SUSAN MADONNA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8871 GORMAN RD SUITE 300
LAUREL MD
20723-5877
US

IV. Provider business mailing address

9649 BELAIR RD SECOND FLOOR
BALTIMORE MD
21236-1100
US

V. Phone/Fax

Practice location:
  • Phone: 301-498-3150
  • Fax: 301-490-2411
Mailing address:
  • Phone: 410-248-2650
  • Fax: 410-248-2656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH59597
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: