Healthcare Provider Details

I. General information

NPI: 1942293600
Provider Name (Legal Business Name): SUSANNAH LILLIE SIMONE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19238 STONEHUE
SAN ANTONIO TX
78258
US

IV. Provider business mailing address

19238 STONEHUE
SAN ANTONIO TX
78258
US

V. Phone/Fax

Practice location:
  • Phone: 210-494-2223
  • Fax: 210-494-6516
Mailing address:
  • Phone: 210-494-2223
  • Fax: 210-494-6516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01059538A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN6665
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: