Provider Demographics
NPI:1447390216
Name:ANDERSON, SUSAN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 S FETTERLY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1605
Mailing Address - Country:US
Mailing Address - Phone:323-780-2216
Mailing Address - Fax:323-264-3771
Practice Address - Street 1:245 S FETTERLY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1605
Practice Address - Country:US
Practice Address - Phone:323-780-2216
Practice Address - Fax:323-264-3771
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW932Medicare ID - Type UnspecifiedHEALTH CENTER
CAW809AMedicare ID - Type UnspecifiedROYBAL