Provider Demographics
NPI:1386619435
Name:STEVENSON, SUSAN M (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:STEVENSON
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 1:6847 KENWHITE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5611
Mailing Address - Country:US
Mailing Address - Phone:214-334-2889
Mailing Address - Fax:
Practice Address - Street 1:6847 KENWHITE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5611
Practice Address - Country:US
Practice Address - Phone:214-334-2889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC22268Medicare UPIN