Provider Demographics
NPI:1285609131
Name:SUSCO, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SUSCO
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 1:241 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1154
Mailing Address - Country:US
Mailing Address - Phone:845-431-8853
Mailing Address - Fax:
Practice Address - Street 1:1386 HATHAWAY DR
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-8973
Practice Address - Country:US
Practice Address - Phone:585-396-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168413-12084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01361962Medicaid
NY01361962Medicaid
NYE20351Medicare UPIN