Provider Demographics
NPI:1053324970
Name:BAN, SUSAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:BAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15000 KENSINGTON PARK DR
Mailing Address - Street 2:STE 360
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1835
Mailing Address - Country:US
Mailing Address - Phone:714-838-5610
Mailing Address - Fax:
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE F
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-838-5610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689633125OtherGROUP NPI
CAW1779OtherGROUP ID
CAI13910Medicare UPIN
CA1689633125OtherGROUP NPI