Provider Demographics
NPI:1720058415
Name:ENLOE-WHITAKER, SUZANNE ELLEN (DO)
Entity type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:ELLEN
Last Name:ENLOE-WHITAKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SUZANNE
Other - Middle Name:ELLEN
Other - Last Name:ENLOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1700 NORTH WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5105
Mailing Address - Country:US
Mailing Address - Phone:909-883-8611
Mailing Address - Fax:909-886-1798
Practice Address - Street 1:1700 NORTH WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5105
Practice Address - Country:US
Practice Address - Phone:909-883-8611
Practice Address - Fax:909-886-1798
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7535207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX75350Medicaid
CA00AX75350Medicaid
CAI35241Medicare UPIN