Provider Demographics
NPI:1306994710
Name:CAVENDER, SUSAN LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:CAVENDER
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 1:1115 LEE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301
Mailing Address - Country:US
Mailing Address - Phone:304-357-4510
Mailing Address - Fax:304-357-4514
Practice Address - Street 1:1115 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-357-4510
Practice Address - Fax:304-357-4514
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2010-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPAAS005202600Medicaid
A72509Medicare UPIN