Provider Demographics
NPI:1326244468
Name:ROUGH, SUSANNE MACANDER (MSRD)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MACANDER
Last Name:ROUGH
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-2130
Mailing Address - Country:US
Mailing Address - Phone:408-294-8662
Mailing Address - Fax:408-294-8662
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-248-7504
Practice Address - Fax:510-248-7057
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00963627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered