1902830409 NPI number — DR. SUSAN M STRATEN D.O.

Table of content: SHIRELL LUCAS (NPI 1366084741)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902830409 NPI number — DR. SUSAN M STRATEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STRATEN
Provider First Name:
SUSAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
QUATRO
Provider Other First Name:
SUSAN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902830409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 N MACARTHUR BLVD STE 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75061-2210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-253-2560
Provider Business Mailing Address Fax Number:
972-253-4218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 N MACARTHUR BLVD STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75061-2210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-253-4315
Provider Business Practice Location Address Fax Number:
972-253-2587
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  J5490 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0485229-07 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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