Provider Demographics
NPI:1912907650
Name:SPADAFORA, SUZANNE GRANADOS (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:GRANADOS
Last Name:SPADAFORA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:NOCHE
Other - Last Name:GRANADOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301 CONCOURSE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5643
Mailing Address - Country:US
Mailing Address - Phone:804-549-4030
Mailing Address - Fax:804-549-4032
Practice Address - Street 1:301 CONCOURSE BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5643
Practice Address - Country:US
Practice Address - Phone:804-549-4030
Practice Address - Fax:804-549-4032
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234502207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010011001Medicaid
7455490OtherAETNA
0300593OtherUNITED HEALTHCARE
230864OtherSOUTHERN HEALTH
P00044699OtherRAILROAD MEDICARE
266822OtherANTHEM
H91764Medicare UPIN
0300593OtherUNITED HEALTHCARE