Provider Demographics
NPI:1699743450
Name:MOWATT, SUSAN LEIGH (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:MOWATT
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 1:619 CHURCH ST
Mailing Address - Street 2:PO BOX 635
Mailing Address - City:HAWLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18428-1444
Mailing Address - Country:US
Mailing Address - Phone:570-226-6077
Mailing Address - Fax:570-561-2082
Practice Address - Street 1:619 CHURCH ST
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:PA
Practice Address - Zip Code:18428-1444
Practice Address - Country:US
Practice Address - Phone:570-226-6077
Practice Address - Fax:570-561-2082
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071840L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018206380008Medicaid
H28912Medicare UPIN
PA043984V96Medicare PIN