Provider Demographics
NPI:1932173119
Name:MCDONALD, SUSAN B (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:MCDONALD
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 1:2626 N CALIFORNIA ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5500
Mailing Address - Country:US
Mailing Address - Phone:209-464-9846
Mailing Address - Fax:209-464-4082
Practice Address - Street 1:2626 N CALIFORNIA ST
Practice Address - Street 2:STE G
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5500
Practice Address - Country:US
Practice Address - Phone:209-464-9846
Practice Address - Fax:209-464-4082
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037520207L00000X
CAC52587207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C525870Medicaid
CA1700836988OtherSTOCKTON ANESTHESIA MED
WA0039515OtherL & I
WA8241945Medicaid
WAMC5531OtherPIERCE COUNTY
WA5539MCOtherINDIVIDUAL BLUE SHIELD
G96034Medicare UPIN
AB09778Medicare ID - Type Unspecified