Provider Demographics
NPI:1558414011
Name:NAZARIAN, SUSANNA MATSEN (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:MATSEN
Last Name:NAZARIAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:LOVELL
Other - Last Name:MATSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1100 WALNUT ST FL 5
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4944
Mailing Address - Country:US
Mailing Address - Phone:215-955-6750
Mailing Address - Fax:
Practice Address - Street 1:1100 WALNUT ST FL 5
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4944
Practice Address - Country:US
Practice Address - Phone:215-955-6750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454561208600000X
WAMD60361960204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1558414011Medicaid