Provider Demographics
NPI:1841276805
Name:ALLEN, SUSAN PARK (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:PARK
Last Name:ALLEN
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 1:320 SUPERIOR AVENUE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-645-9100
Mailing Address - Fax:949-809-9640
Practice Address - Street 1:320 SUPERIOR AVENUE
Practice Address - Street 2:SUITE 290
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-645-9100
Practice Address - Fax:949-809-9640
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG061446207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G614460OtherBLUE SHIELD
CA00G61440OtherMEDICAL
F02340Medicare UPIN
WG61446EMedicare ID - Type Unspecified