Provider Demographics
NPI:1205945151
Name:STEPHENS DIERAUF, SUSAN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:STEPHENS DIERAUF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ELIZABETH
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 892
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:CA
Mailing Address - Zip Code:94957-0892
Mailing Address - Country:US
Mailing Address - Phone:415-459-3094
Mailing Address - Fax:
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:KAISER RICHMOND CAMPUS
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801
Practice Address - Country:US
Practice Address - Phone:510-307-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 21292208000000X
CAG 080393208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics