Provider Demographics
NPI:1255373247
Name:WILSON, SUZANNE LEE (MB, CHB)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MB, CHB
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:LEE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MB, CHB
Mailing Address - Street 1:6804 SARONI DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2347
Mailing Address - Country:US
Mailing Address - Phone:510-339-6619
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:510-428-3590
Practice Address - Fax:510-601-3974
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35721208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics