Provider Demographics
NPI:1720076458
Name:ST PIERRE, SUSAN MARIE (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:ST PIERRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:4 SCAMMON ST STE 19-200
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-5121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 HILL RD STE 14
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947
Practice Address - Country:US
Practice Address - Phone:415-895-1441
Practice Address - Fax:415-895-1288
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14943207Q00000X
ME1409207Q00000X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM34330534Medicaid
CO48178845Medicaid
AZ796386Medicaid
ME243530099Medicaid
HBP16Medicare ID - Type Unspecified
AZ796386Medicaid
MEMM941301Medicare PIN