Healthcare Provider Details

I. General information

NPI: 1629047089
Provider Name (Legal Business Name): SUZANNE ELIZABETH DVERGSTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SOUTH WILLIAMSON AVENUE
ELON NC
27244
US

IV. Provider business mailing address

1234 HUFFMAN MILL ROAD
BURLINGTON NC
27215-8700
US

V. Phone/Fax

Practice location:
  • Phone: 336-538-2516
  • Fax: 336-584-6811
Mailing address:
  • Phone: 336-538-1234
  • Fax: 336-584-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2101-01891
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier50456700
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: