Healthcare Provider Details

I. General information

NPI: 1801138631
Provider Name (Legal Business Name): SUSAN E SEIDEMAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23601 AVALON BLVD SUITE 105
CARSON CA
90745-5582
US

IV. Provider business mailing address

23601 AVALON BLVD SUITE 105
CARSON CA
90745-5582
US

V. Phone/Fax

Practice location:
  • Phone: 310-595-4367
  • Fax: 310-549-5022
Mailing address:
  • Phone: 310-595-4367
  • Fax: 310-549-5022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG33438
License Number StateCA

VIII. Authorized Official

Name: MISS LOBNA ANAIM
Title or Position: ADMINISTRATOR
Credential:
Phone: 714-683-2970