Provider Demographics
NPI:1487092078
Name:DRAKE, SUSIE C (MD)
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:C
Last Name:DRAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:CHEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:123 HOSPITAL DR
Mailing Address - Street 2:STE 1002
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:920-261-8225
Mailing Address - Fax:920-261-5343
Practice Address - Street 1:2880 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3644
Practice Address - Country:US
Practice Address - Phone:608-263-7171
Practice Address - Fax:608-265-8060
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI66916207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program