Basic Information
| Provider Information | |||||||||
| NPI: | 1871536805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6431 FANNIN ST # 2.130 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007626 | ||||||||
| FaxNumber: | 7135007639 | ||||||||
| Practice Location | |||||||||
| Address1: | 6431 FANNIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007626 | ||||||||
| FaxNumber: | 7135007639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | G8435 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | G8435 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 82445R | 01 | TX | BCBS | OTHER | 138212902 | 01 | TX | CSHCN | OTHER | 138212917 | 05 | TX | MEDICAID | 138212918 | 05 | TX | MEDICAID | 138212914 | 01 | TX | CSHCN | OTHER |