Healthcare Provider Details

I. General information

NPI: 1275660268
Provider Name (Legal Business Name): SUSHMA Z. MAGNUSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 04/11/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 BRODERICK STREET BRODERICK ADULT RESIDENTIAL FACILITY
ALBANY CA
94115
US

IV. Provider business mailing address

1330 PORTLAND AVE
ALBANY CA
94706-1449
US

V. Phone/Fax

Practice location:
  • Phone: 415-292-1760
  • Fax: 415-292-2511
Mailing address:
  • Phone: 510-559-0692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG70632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: