Provider Demographics
NPI:1790979813
Name:CULVERHOUSE, SUSAN HOWARD (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:HOWARD
Last Name:CULVERHOUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:3801 E HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-5318
Practice Address - Country:US
Practice Address - Phone:850-932-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107608207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12145140OtherCAQH
FLDO586ZMedicare PIN