Provider Demographics
NPI:1285730267
Name:WOLF, SUSAN IRENE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:IRENE
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:IRENE
Other - Last Name:WOLF-FELDESMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10180 SE SUNNYSIDE RD
Mailing Address - Street 2:KAISER SUNNYSIDE MEDICAL OFFICE
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-652-2880
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:KAISER SUNNYSIDE MEDICAL OFFICE
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-652-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD165282085B0100X, 2085R0202X, 2085U0001X
WAMD000343772085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound