Provider Demographics
NPI:1629076856
Name:KAWESKI, SUSAN (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:KAWESKI
Suffix:
Gender:F
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8415 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941
Mailing Address - Country:US
Mailing Address - Phone:619-464-9876
Mailing Address - Fax:619-464-9877
Practice Address - Street 1:8415 GRANT AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5303
Practice Address - Country:US
Practice Address - Phone:619-464-9876
Practice Address - Fax:616-464-9877
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAG53909170100000X
CAG539092086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1145416243Medicaid
CA1629076856Medicaid