Provider Demographics
NPI:1861792665
Name:CHORTKOFF, SUSAN CRAWFORD (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CRAWFORD
Last Name:CHORTKOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEIGH
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:JOHN A MORAN EYE CTR
Mailing Address - Street 2:65 NORTH MARIO CAPECCHI DRIVE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-2352
Mailing Address - Fax:
Practice Address - Street 1:JOHN A MORAN EYE CTR
Practice Address - Street 2:65 NORTH MARIO CAPECCHI DRIVE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7116185-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology