Provider Demographics
NPI:1043246994
Name:SUSNOW, AMY BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:BLAKE
Last Name:SUSNOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:S
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-2274
Practice Address - Country:US
Practice Address - Phone:608-263-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0058101207SG0201X
WAFE60028232390200000X
WI390200000X
WI56132207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO028673OtherKAISER COMMERCIAL NUMBER