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General NPI Number Information
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NPI Number | 1124056163
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Entity Type | Individual
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Provider Name | JASON V. SUSTERSIC D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/29/2006
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Last Update Date | 12/23/2020
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Provider Practice Location Address
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Address Line | 6571 BRECKSVILLE RD
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City | INDEPENDENCE
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State | OH
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Zip | 44131-4848
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Country | US
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Telephone | 216-233-5996
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Fax |
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Provider Business Mailing Address
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Address Line | 5617 BIDDULPH AVE
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City | CLEVELAND
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State | OH
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Zip | 44144-3504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 34-008460
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License Number State | OH
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