Provider Demographics
NPI:1730179284
Name:DEMUTH, SUSAN A (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:DEMUTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:A
Other - Last Name:SHULTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:KIMBROUGH AMBULATORY CARE CENTER
Mailing Address - Street 2:ATTN: MCXR-CR 2480 LLEWELLYN AVE.
Mailing Address - City:FT. MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755
Mailing Address - Country:US
Mailing Address - Phone:301-677-8270
Mailing Address - Fax:301-677-8176
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5800
Practice Address - Country:US
Practice Address - Phone:301-677-8641
Practice Address - Fax:301-677-8485
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101037909208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVA D000Medicare UPIN