Provider Demographics
NPI:1689677122
Name:CANNING, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:CANNING
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 1:13600 MARINA POINTE DR UNIT 1507
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-9253
Mailing Address - Country:US
Mailing Address - Phone:301-704-4398
Mailing Address - Fax:
Practice Address - Street 1:3966 MARCASEL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4616
Practice Address - Country:US
Practice Address - Phone:949-482-1930
Practice Address - Fax:216-273-9998
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-28
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG174181207N00000X
DCMD043939207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF87171Medicare UPIN
MD406255Medicare PIN
MD406255Medicare PIN