Provider Demographics
NPI:1285668707
Name:CORDES, SUSAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:CORDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:SLAKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1111 EXPOSITION BLVD BLDG 700
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4314
Mailing Address - Country:US
Mailing Address - Phone:916-736-3399
Mailing Address - Fax:916-736-3350
Practice Address - Street 1:10200 TRINITY PKWY STE 201
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7288
Practice Address - Country:US
Practice Address - Phone:209-952-0483
Practice Address - Fax:209-478-5785
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043929A207Y00000X
CAG129761207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200167750Medicaid
IN200167750Medicaid
IN037690WMedicare PIN
ING08472Medicare UPIN