Provider Demographics
NPI:1275660268
Name:MAGNUSON, SUSHMA Z (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHMA
Middle Name:Z
Last Name:MAGNUSON
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 1:1330 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1449
Mailing Address - Country:US
Mailing Address - Phone:510-559-0692
Mailing Address - Fax:
Practice Address - Street 1:1421 BRODERICK STREET
Practice Address - Street 2:BRODERICK ADULT RESIDENTIAL FACILITY
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-292-1760
Practice Address - Fax:415-292-2511
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70632207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
018473OtherSFGH INTERNAL USE ONLY-COMMERCIAL NUMBER
F66930Medicare UPIN