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NPI Code Detail

MEDICARE: DR. MICHAEL VITTORIO SUSANO M.D.

MEDICARE: DR. MICHAEL VITTORIO SUSANO M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry Physician025874LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1063440105
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MICHAEL VITTORIO SUSANO M.D.
Provider Business Mailing Address
First Line : 107 MEDICAL CIR
Second Line :
City : SULPHUR SPRINGS
State : TX
Zip : 75482-2138
Country : US
Telephone Number : 318-869-2044
Fax Number :
Provider Business Practice Location Address
First Line : 1310 N HEARNE AVE
Second Line :
City : SHREVEPORT
State : LA
Zip : 71107-6516
Country : US
Telephone Number : 318-676-5111
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/29/2006
Last Update Date : 05/19/2016

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