Provider Demographics
NPI:1902902083
Name:GRESSER, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:GRESSER
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 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:NVRH CORNER MEDICAL
Practice Address - Street 2:195 INDUSTRIAL PKWY
Practice Address - City:LYNDON
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008478207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN315Medicaid
VTVN0315Medicare ID - Type Unspecified
VTF00202Medicare UPIN