Provider Demographics
NPI:1184982530
Name:KAPUSTKA, SUSAN LYNN (DPM)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LYNN
Last Name:KAPUSTKA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9711 S MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3316
Mailing Address - Country:US
Mailing Address - Phone:815-455-8090
Mailing Address - Fax:
Practice Address - Street 1:9711 S MUIRFIELD DR
Practice Address - Street 2:
Practice Address - City:VILLAGE OF LAKEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60014-3316
Practice Address - Country:US
Practice Address - Phone:815-455-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003622213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery