Provider Demographics
NPI:1215120621
Name:PERKO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PERKO
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 1:100 SUNSET STRIP DR
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-4243
Mailing Address - Country:US
Mailing Address - Phone:352-475-5385
Mailing Address - Fax:
Practice Address - Street 1:100 SUNSET STRIP DR
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:FL
Practice Address - Zip Code:32640-4243
Practice Address - Country:US
Practice Address - Phone:352-475-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA37145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC2391OtherBLUE CROSS/BLUE SHIELD