Provider Demographics
NPI:1366427940
Name:MADONNA, SUSAN (DO)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:MADONNA
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:9649 BELAIR RD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1100
Mailing Address - Country:US
Mailing Address - Phone:410-248-2650
Mailing Address - Fax:410-248-2656
Practice Address - Street 1:8871 GORMAN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-5877
Practice Address - Country:US
Practice Address - Phone:301-498-3150
Practice Address - Fax:301-490-2411
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2011-02-04
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Provider Licenses
StateLicense IDTaxonomies
MDH59597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN