Healthcare Provider Details

I. General information

NPI: 1619486644
Provider Name (Legal Business Name): SUSAN VIRGINIA MASSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 WILSHIRE BLVD STE 300
BEVERLY HILLS CA
90211-1959
US

IV. Provider business mailing address

1041 S CORNING ST APT 203
LOS ANGELES CA
90035-2040
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-8002
  • Fax:
Mailing address:
  • Phone: 631-223-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number21114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: