Provider Demographics
NPI:1912948530
Name:HAEFNER, SUSAN MOORE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MOORE
Last Name:HAEFNER
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 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-773-2559
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-773-2120
Practice Address - Fax:928-213-2189
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL49612080P0203X
AZ270972080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ705347Medicaid
TX152394601Medicaid
AZ705347Medicaid
H65420Medicare UPIN