MEDICARE: MS. SUSUN MICHAELS DO

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
1	207N00000X	Dermatology Physician	DO1612	NV
2	207N00000X	Dermatology Physician	005520	AZ

General Provider Information

NPI Number	:	1366611311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSUN MICHAELS DO

Provider Business Mailing Address
First Line	:	2285 CORPORATE CIR
Second Line	:	STE 200
City	:	HENDERSON
State	:	NV
Zip	:	89074-7759
Country	:	US
Telephone Number	:	702-360-2763
Fax Number	:	949-783-2880

Provider Business Practice Location Address
First Line	:	8205 W WARM SPRINGS RD
Second Line	:	SUITE 190
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3645
Country	:	US
Telephone Number	:	702-588-6730
Fax Number	:	702-588-6732

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	03/15/2016

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