Provider Demographics
NPI:1073556098
Name:STEVENS, SUSAN KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KATHRYN
Last Name:STEVENS
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:P.O. BOX 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:
Practice Address - Street 1:1101 VAN NESS AVE FL 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6919
Practice Address - Country:US
Practice Address - Phone:415-600-0800
Practice Address - Fax:415-447-6335
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG568602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G568600Medicaid
CA300134152OtherRAILROAD MEDICARE
CAAR816VMedicare PIN
CA00G568600Medicare PIN
CAB74521Medicare UPIN
CAAR816ZMedicare PIN
CA300134152OtherRAILROAD MEDICARE
CA00G568600Medicaid