Provider Demographics
NPI:1902965643
Name:RO, SUSIE (MD)
Entity Type:Individual
Prefix:
First Name:SUSIE
Middle Name:
Last Name:RO
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 1:34503 9TH AVE S STE 230
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8726
Mailing Address - Country:US
Mailing Address - Phone:253-838-3103
Mailing Address - Fax:253-838-7134
Practice Address - Street 1:34503 9TH AVE S STE 230
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8726
Practice Address - Country:US
Practice Address - Phone:253-838-3103
Practice Address - Fax:253-838-7134
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048739204R00000X, 2084N0600X, 2084N0400X
MI43015111522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1056456Medicaid