Healthcare Provider Details

I. General information

NPI: 1548326796
Provider Name (Legal Business Name): SUSAN M KSIAZEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 PLAZA DR
WAUSAU WI
54401-4192
US

IV. Provider business mailing address

1000 N OAK AVE
MARSHFIELD WI
54449-5703
US

V. Phone/Fax

Practice location:
  • Phone: 715-841-4950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036104545
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number70365
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: