Healthcare Provider Details

I. General information

NPI: 1720205347
Provider Name (Legal Business Name): EDUARDO M SUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE SUITE 103
CHARLESTON WV
25302
US

IV. Provider business mailing address

3110 MACCORKLE AVE SE
CHARLESTON WV
25304-1210
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-1296
  • Fax: 304-293-6963
Mailing address:
  • Phone: 304-347-1300
  • Fax: 304-293-6963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10971
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: