Provider Demographics
NPI:1316904105
Name:ELACQUA, MARY SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUSAN
Last Name:ELACQUA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:101 JORDAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8343
Practice Address - Country:US
Practice Address - Phone:518-274-0476
Practice Address - Fax:518-274-0497
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-10-06
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Provider Licenses
StateLicense IDTaxonomies
NY149514207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY141655014OtherEMPIRE PLAN
NY160007874OtherRAILROAD MEDICARE
NY16152OtherMVP
NY00858755Medicaid
NY113801OtherWELLCARE
NY13801OtherGHIHMO
NY10000563OtherCDPHP
NY52E361OtherBLUE CROSS
NY000416081001OtherBLUE SHIELD
NY0015055OtherGHI
NY141655014OtherUNITED HEALTHCARE
NY0005361476OtherAETNA
NY040426006334OtherFIDELIS
NY00020780401OtherUNIVERA
NY141655014OtherEMPIRE PLAN
NY160007874OtherRAILROAD MEDICARE
NY141655014OtherUNITED HEALTHCARE