Provider Demographics
NPI:1316155047
Name:BLANK, SUSAN K (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:BLANK
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 1:924 RUGBY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-1606
Mailing Address - Country:US
Mailing Address - Phone:434-466-3147
Mailing Address - Fax:
Practice Address - Street 1:924 RUGBY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-1606
Practice Address - Country:US
Practice Address - Phone:434-466-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237491207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01065575Medicare PIN
VAVAA101951Medicare PIN