Provider Demographics
NPI:1063781326
Name:IRVING, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:IRVING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WHISPERING PINE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4294
Mailing Address - Country:US
Mailing Address - Phone:770-985-4257
Mailing Address - Fax:770-985-4258
Practice Address - Street 1:15 WHISPERING PINE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-4294
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:770-985-4258
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2013208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery