Provider Demographics
NPI:1144853995
Name:SUSSMAN, MARDA (ND)
Entity type:Individual
Prefix:
First Name:MARDA
Middle Name:
Last Name:SUSSMAN
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4047 RIVOLI
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-9025
Mailing Address - Country:US
Mailing Address - Phone:917-748-3028
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE STE U3
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4627
Practice Address - Country:US
Practice Address - Phone:714-754-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND1052175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath