Provider Demographics
NPI:1083828297
Name:JOHNSON, SUSAN RIDEOUT (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:RIDEOUT
Last Name:JOHNSON
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:PO BOX 1621
Mailing Address - Street 2:54 W GRASS VALLEY ST
Mailing Address - City:COLFAX
Mailing Address - State:CA
Mailing Address - Zip Code:95713-9463
Mailing Address - Country:US
Mailing Address - Phone:916-638-8758
Mailing Address - Fax:
Practice Address - Street 1:54 WEST GRASS VALLEY STREET
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:CA
Practice Address - Zip Code:95713-9463
Practice Address - Country:US
Practice Address - Phone:916-638-8758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG599192080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics