Provider Demographics
NPI:1912959958
Name:MYERS, SUSAN MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:MYERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:15294 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2029
Mailing Address - Country:US
Mailing Address - Phone:510-326-2145
Mailing Address - Fax:510-317-9419
Practice Address - Street 1:15294 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2029
Practice Address - Country:US
Practice Address - Phone:510-326-2145
Practice Address - Fax:510-317-9419
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7213828OtherAETNA
CADC0284590OtherBLUE SHIELD PROVIDER #
CAP00194781Medicare PIN
CADC0284590Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAU93556Medicare UPIN