Provider Demographics
NPI:1770510919
Name:PEREIRA, SUSAN A (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:PEREIRA
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 1:110 W AMERICAN CANYON RD
Mailing Address - Street 2:SUITE L4 #125
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-4196
Mailing Address - Country:US
Mailing Address - Phone:707-815-0063
Mailing Address - Fax:707-676-8628
Practice Address - Street 1:110 W AMERICAN CANYON RD
Practice Address - Street 2:SUITE L4 #125
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-4196
Practice Address - Country:US
Practice Address - Phone:707-815-0063
Practice Address - Fax:707-676-8628
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2012-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA70499207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A704992Medicaid
CAH20633Medicare UPIN
CA00A704992Medicaid