Provider Demographics
NPI:1699883108
Name:DAVIS, SUSAN L (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4268
Practice Address - Fax:682-885-7956
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH42722080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7196161OtherCIGNA PIN
TX00U87ZOtherBCBSTX GRP PIN
TX111357100OtherFIRSTCARE PIN
TX134924308Medicaid
TX1640402OtherFIRSTHEALTH PIN
1750369203OtherGRP NPI NUMBER
TX10009851OtherAMERIGROUP PIN
TX124118OtherSUPERIOR PIN
TX134924309OtherCSHCN
TX84041GOtherBCBSTX IND PIN
TX1056493OtherUHC PIN
TX425611OtherPHCS PIN
TX4640155OtherAETNA PIN
TX4640155OtherAETNA PIN
TXB102501Medicare PIN