Provider Demographics
NPI:1033115688
Name:SUSSMAN, CLIFFORD L (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:L
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W. FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1102
Mailing Address - Country:US
Mailing Address - Phone:909-599-9921
Mailing Address - Fax:909-592-3147
Practice Address - Street 1:150 W. FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1102
Practice Address - Country:US
Practice Address - Phone:909-599-9921
Practice Address - Fax:909-592-3147
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-12-11
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
CAA45906174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF7892Medicare UPIN
CAA45906AMedicare ID - Type Unspecified
F78962Medicare UPIN
WA45906AMedicare PIN