Provider Demographics
NPI:1366522617
Name:GILLESPIE, SUSAN LANELLE (MD, PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LANELLE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2303
Mailing Address - Country:US
Mailing Address - Phone:832-822-1038
Mailing Address - Fax:832-825-1281
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2303
Practice Address - Country:US
Practice Address - Phone:832-822-1038
Practice Address - Fax:832-825-1281
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2960208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178503201Medicaid
H18858Medicare UPIN
TX178503201Medicaid