Provider Demographics
NPI:1295909752
Name:SUSA, JONATHAN L I (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:L
Last Name:SUSA
Suffix:I
Gender:M
Credentials:DO
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2651 HILLCREST DRIVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4439
Mailing Address - Country:US
Mailing Address - Phone:715-531-6800
Mailing Address - Fax:715-531-6801
Practice Address - Street 1:2651 HILLCREST DRIVE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4439
Practice Address - Country:US
Practice Address - Phone:715-531-6800
Practice Address - Fax:715-531-6801
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2023-06-01
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI51842207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43549400Medicaid