Provider Demographics
NPI:1861718132
Name:SUSNOW, LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:SUSNOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S SIERRA AVE
Mailing Address - Street 2:#342
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2234
Mailing Address - Country:US
Mailing Address - Phone:858-523-0145
Mailing Address - Fax:
Practice Address - Street 1:429 S SIERRA AVE
Practice Address - Street 2:#342
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2234
Practice Address - Country:US
Practice Address - Phone:858-523-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27739207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A43473Medicare UPIN