Provider Demographics
NPI:1508843368
Name:SUSAN PARK ALLEN MD INC
Entity Type:Organization
Organization Name:SUSAN PARK ALLEN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:PARK
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-645-9100
Mailing Address - Street 1:320 SUPERIOR AVENUE
Mailing Address - Street 2:SUITE #280
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-645-9100
Mailing Address - Fax:949-645-9650
Practice Address - Street 1:320 SUPERIOR AVENUE
Practice Address - Street 2:SUITE #280
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-645-9100
Practice Address - Fax:949-645-9650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G614460Medicaid
00G614460OtherBLUE SHIELD
00G614460OtherBLUE SHIELD
CA00G614460Medicaid