Provider Demographics
NPI:1700803608
Name:URSIN, SUSONNE ANNETTE (MD)
Entity type:Individual
Prefix:
First Name:SUSONNE
Middle Name:ANNETTE
Last Name:URSIN
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 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS, SECTION OF GENETICS
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-6076
Mailing Address - Fax:318-675-6059
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS, SECTION OF GENETICS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-6076
Practice Address - Fax:318-675-6059
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013853207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1194484Medicaid
LA5L740F600Medicare ID - Type Unspecified
LAB61461Medicare UPIN