Provider Demographics
NPI:1447255625
Name:SUICO, VIVIAN R (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:R
Last Name:SUICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-3781
Mailing Address - Country:US
Mailing Address - Phone:440-240-1655
Mailing Address - Fax:440-245-1218
Practice Address - Street 1:3745 GROVE AVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-2734
Practice Address - Country:US
Practice Address - Phone:440-240-1655
Practice Address - Fax:440-245-1218
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35046291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0477532Medicaid
OHSU0501533Medicare ID - Type UnspecifiedMEDICARE NUMBER
OH0477532Medicaid