Healthcare Provider Details

I. General information

NPI: 1992763981
Provider Name (Legal Business Name): SUSAN LYASKO KLUGEWICZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W ELK AVE
ELIZABETHTON TN
37643
US

IV. Provider business mailing address

401 E MAIN ST
JOHNSON CITY TN
37601-4877
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-2584
  • Fax: 423-722-2060
Mailing address:
  • Phone: 423-929-2584
  • Fax: 423-722-2060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME78055
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD45116
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: