Provider Demographics
NPI:1063440105
Name:SUSANO, MICHAEL VITTORIO (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VITTORIO
Last Name:SUSANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-2138
Mailing Address - Country:US
Mailing Address - Phone:318-869-2044
Mailing Address - Fax:
Practice Address - Street 1:1310 N HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6516
Practice Address - Country:US
Practice Address - Phone:318-676-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0258742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1041840Medicaid
LA1041840Medicaid
LAI39772Medicare UPIN