Provider Demographics
NPI:1992911895
Name:BACSIK, SUSAN L (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BACSIK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-3613
Mailing Address - Country:US
Mailing Address - Phone:817-946-0790
Mailing Address - Fax:
Practice Address - Street 1:8350 N CENTRAL EXPY STE M1025
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-1615
Practice Address - Country:US
Practice Address - Phone:214-368-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6511208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics