Provider Demographics
NPI:1356340442
Name:DETHMAN, SUSAN (CDR)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:DETHMAN
Suffix:
Gender:F
Credentials:CDR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1475
Mailing Address - Country:US
Mailing Address - Phone:405-257-7318
Mailing Address - Fax:405-257-2696
Practice Address - Street 1:HWY 56 & 270 JUNCTION
Practice Address - Street 2:
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884
Practice Address - Country:US
Practice Address - Phone:405-257-7318
Practice Address - Fax:405-257-2696
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT202394133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8HZW44Medicare ID - Type Unspecified