Provider Demographics
NPI:1356420384
Name:GOODALE, SUSAN C (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:GOODALE
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 1:393 N DUNLAP ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-645-4693
Mailing Address - Fax:651-645-6503
Practice Address - Street 1:393 N DUNLAP ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-645-4693
Practice Address - Fax:651-645-6503
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN38423208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F47966Medicare UPIN