Provider Demographics
NPI:1134185556
Name:JENSEN, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:JENSEN
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 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:2570 ROUTE 9W
Practice Address - Street 2:STE 4
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518-1323
Practice Address - Country:US
Practice Address - Phone:845-534-1505
Practice Address - Fax:845-534-1504
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138024207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
30A161L663OtherMEDICARE
NY00510563Medicaid
NY30A161Medicare ID - Type UnspecifiedMEDICARE
NY00510563Medicaid