Provider Demographics
NPI:1740345867
Name:MCMAHON, SUSAN F
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:F
Last Name:MCMAHON
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 1:53 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4803
Mailing Address - Country:US
Mailing Address - Phone:973-615-3108
Mailing Address - Fax:
Practice Address - Street 1:460 W 34TH ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:212-273-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY005689-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9268E1Medicare UPIN