MEDICARE: DR. SUSAN LONDERVILLE M.D.

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	207R00000X	Internal Medicine Physician	G71492	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00G714920	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1760419055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN LONDERVILLE M.D.

Provider Business Mailing Address
First Line	:	3871 PIEDMONT AVE
Second Line	:	#353
City	:	OAKLAND
State	:	CA
Zip	:	94611-5378
Country	:	US
Telephone Number	:	510-655-4786
Fax Number	:

Provider Business Practice Location Address
First Line	:	1546 LA LOMA AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94708-2034
Country	:	US
Telephone Number	:	510-868-4181
Fax Number	:

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	07/08/2007

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