Provider Demographics
NPI:1598142366
Name:WALL, SUSAN DIANE
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DIANE
Last Name:WALL
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:505 PARNASSUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:415-476-1537
Mailing Address - Fax:415-476-0616
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-476-1537
Practice Address - Fax:415-476-0616
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG419752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology