Provider Demographics
NPI:1417954793
Name:KEISNER, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:KEISNER
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 1:3401 W SUNFLOWER AVE.
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704
Mailing Address - Country:US
Mailing Address - Phone:714-619-8777
Mailing Address - Fax:714-619-8770
Practice Address - Street 1:3401 W. SUNFLOWER AVE.
Practice Address - Street 2:SUITE 250
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704
Practice Address - Country:US
Practice Address - Phone:714-619-8777
Practice Address - Fax:714-619-8770
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C418200OtherMEDI CAL
F52358Medicare UPIN
CAF52358Medicare UPIN