Provider Demographics
NPI:1659309896
Name:MACKENSEN, SUSAN J (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MACKENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 PREUSS RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-4313
Mailing Address - Country:US
Mailing Address - Phone:310-838-3092
Mailing Address - Fax:310-287-0656
Practice Address - Street 1:1809 PREUSS RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-4313
Practice Address - Country:US
Practice Address - Phone:310-838-3092
Practice Address - Fax:310-287-0656
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE46013208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA46013AMedicare ID - Type Unspecified
CAE93831Medicare UPIN
CAWA46013DMedicare ID - Type Unspecified
CAWA46013FMedicare ID - Type Unspecified
CAWA46013EMedicare ID - Type Unspecified