MEDICARE: SUESAN PEDERSEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0800X	Psychiatry Physician	R7085	TX

General Provider Information

NPI Number	:	1558603837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUESAN PEDERSEN MD

Provider Business Mailing Address
First Line	:	425 N DATE ST
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-3413
Country	:	US
Telephone Number	:	760-737-6931
Fax Number	:	760-741-2782

Provider Business Practice Location Address
First Line	:	401 E VALLEY PKWY
Second Line	:
City	:	ESCONDIDO
State	:	CA
Zip	:	92025-3317
Country	:	US
Telephone Number	:	760-737-6931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	06/17/2020

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