Provider Demographics
NPI:1104076058
Name:DOUBRAVA, SUZANNE (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:DOUBRAVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE # CAB2200
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-214-3940
Mailing Address - Fax:215-214-1425
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-214-3940
Practice Address - Fax:215-214-1425
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA081854002084P0800X
PAMD4663122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00919249OtherRR MCR PTAN
NJ0211427Medicaid
NJ153291APHMedicare PIN