Provider Demographics
NPI:1619486644
Name:MASSEY, SUSAN VIRGINIA
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:VIRGINIA
Last Name:MASSEY
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 1:1041 S CORNING ST APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2040
Mailing Address - Country:US
Mailing Address - Phone:631-223-5404
Mailing Address - Fax:
Practice Address - Street 1:8900 WILSHIRE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1959
Practice Address - Country:US
Practice Address - Phone:310-273-8002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA211142086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology