Healthcare Provider Details

I. General information

NPI: 1134111214
Provider Name (Legal Business Name): SUSAN D ETTINGER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 COWPATH RD SUITE 1
LANSDALE PA
19446-1152
US

IV. Provider business mailing address

108 COWPATH RD SUITE 1
LANSDALE PA
19446-1152
US

V. Phone/Fax

Practice location:
  • Phone: 215-855-1599
  • Fax: 215-855-1589
Mailing address:
  • Phone: 215-855-1599
  • Fax: 215-855-1589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS004397L
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: