Provider Demographics
NPI:1447261706
Name:MESSERLY, SUSAN O (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:O
Last Name:MESSERLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SOUTH GIBSON STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-2121
Mailing Address - Fax:
Practice Address - Street 1:143 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33749208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30056100Medicaid
WI004261030Medicare ID - Type Unspecified
WI30056100Medicaid