Provider Demographics
NPI:1891790630
Name:HOFFMAN, SUSAN H (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:HOFFMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:H
Other - Last Name:TEAFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:79 BENTON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1717
Mailing Address - Country:US
Mailing Address - Phone:805-440-3368
Mailing Address - Fax:805-481-8237
Practice Address - Street 1:79 BENTON WAY
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1717
Practice Address - Country:US
Practice Address - Phone:805-440-3368
Practice Address - Fax:805-481-8237
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79922208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00B799220OtherBLUE SHIELD OF CA PIN
CAG79922OtherMEDICAL LICENSE #
GA00G799220Medicaid
GA00G799220Medicaid