Provider Demographics
NPI:1366410920
Name:SCHROEDER, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:SCHROEDER
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1259 LAKE PLAZA DR STE 270
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3560
Mailing Address - Country:US
Mailing Address - Phone:719-421-7132
Mailing Address - Fax:
Practice Address - Street 1:1259 LAKE PLAZA DR STE 270
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3560
Practice Address - Country:US
Practice Address - Phone:719-421-7132
Practice Address - Fax:719-639-7903
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40371174400000X
NJ25MA08824100207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC471198Medicare ID - Type Unspecified
COH24578Medicare UPIN