Provider Demographics
NPI:1730169186
Name:HENDRICKS, SUSAN K (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:K
Last Name:HENDRICKS
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 1:590 15TH ST S
Mailing Address - Street 2:APT 145
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-2872
Mailing Address - Country:US
Mailing Address - Phone:703-418-0234
Mailing Address - Fax:
Practice Address - Street 1:590 15TH ST S
Practice Address - Street 2:APT 145
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-2872
Practice Address - Country:US
Practice Address - Phone:703-418-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI42010421512080N0001X
LA304262207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA2184OtherRAILROAD MEDICARE
LA2433610Medicaid
MI4504927Medicaid
MS06979534Medicaid
LA545890YH3UMedicare PIN
LA2433610Medicaid
MI4504927Medicaid