Provider Demographics
NPI:1083786834
Name:MACMILLAN, SUSAN L M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L M
Last Name:MACMILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:MCLAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:10725 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-7967
Practice Address - Country:US
Practice Address - Phone:916-631-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68964207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A689640Medicaid
H05014Medicare UPIN
CA00A689640Medicaid