Provider Demographics
NPI:1861453086
Name:CUNNINGHAM, SUSAN L (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:29598 ASHTON CT
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-6417
Mailing Address - Country:US
Mailing Address - Phone:208-908-1158
Mailing Address - Fax:208-888-5062
Practice Address - Street 1:2020 PALOMINO LN STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB02003111N00000X
IDCHIA-1251111N00000X
NVDO28602085R0202X
CA20A15154208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No111N00000XChiropractic ProvidersChiropractor
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV08333Medicare UPIN
NV102054Medicare ID - Type Unspecified