Healthcare Provider Details

I. General information

NPI: 1215256599
Provider Name (Legal Business Name): SUSAN LYLA ADHAM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4053 LONE TREE WAY SUITE 101
ANTIOCH CA
94531-6210
US

IV. Provider business mailing address

4053 LONE TREE WAY STE 101
ANTIOCH CA
94531-6210
US

V. Phone/Fax

Practice location:
  • Phone: 925-756-3400
  • Fax: 925-757-6387
Mailing address:
  • Phone: 925-756-3400
  • Fax: 925-757-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA108068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: