Provider Demographics
NPI:1811966500
Name:GOLTZ, SUSAN MAVIS (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MAVIS
Last Name:GOLTZ
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 1:1000 E 1ST ST
Mailing Address - Street 2:STE. LL
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-722-5629
Mailing Address - Fax:218-722-5148
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:STE. LL
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-722-5629
Practice Address - Fax:218-722-5148
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33349174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN111079OtherUCARE
WI31754000Medicaid
A005OtherTRICARE
MN2055782400Medicaid
0725685OtherMEDICA
MN2F932SWOtherBLUE CROSS BLUE SHIELD
346005OtherPREFERRED ONE
MNHP22608OtherHEALTH PARTNERS
WI31754000Medicaid
WI31754000Medicaid