Provider Demographics
NPI:1306956487
Name:KORP, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KORP
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 1:540 MADISON OAK
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-496-1217
Mailing Address - Fax:210-496-1849
Practice Address - Street 1:540 MADISON OAK
Practice Address - Street 2:SUITE 140
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-496-1217
Practice Address - Fax:210-496-1849
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXB5264163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
00L33KMedicare ID - Type Unspecified
C18018Medicare UPIN