Provider Demographics
NPI:1912392713
Name:PROUM, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PROUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:
Practice Address - Street 1:393 E WALNUT ST FL 3
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91188-2757
Practice Address - Country:US
Practice Address - Phone:877-608-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA160299208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program