Provider Demographics
NPI:1588954325
Name:SUSSENBACH, EVAN (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:SUSSENBACH
Suffix:
Gender:M
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:PO BOX 11407
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-3035
Mailing Address - Country:US
Mailing Address - Phone:706-323-3491
Mailing Address - Fax:
Practice Address - Street 1:2616 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5323
Practice Address - Country:US
Practice Address - Phone:706-323-3491
Practice Address - Fax:706-660-9191
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA069646207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program