Provider Demographics
NPI:1891720645
Name:SUSMAN, KENNETH H (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:SUSMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:981 N ALTA VISTA
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016
Mailing Address - Country:US
Mailing Address - Phone:213-307-0151
Mailing Address - Fax:
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 509
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-938-3338
Practice Address - Fax:323-938-9379
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3949213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU49677Medicare UPIN