Provider Demographics
NPI:1013974815
Name:PODOLSKY, SUSAN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROSE
Last Name:PODOLSKY
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 1:2603 PATTERSON RD
Mailing Address - Street 2:STE 1
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-3407
Mailing Address - Country:US
Mailing Address - Phone:209-869-5678
Mailing Address - Fax:209-869-6357
Practice Address - Street 1:2603 PATTERSON RD
Practice Address - Street 2:STE 1
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-3407
Practice Address - Country:US
Practice Address - Phone:209-869-5678
Practice Address - Fax:209-869-6357
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62868207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076050Medicaid
CAZZZ13336ZMedicare PIN
CAE25237Medicare UPIN
CAGR0076050Medicaid