Healthcare Provider Details

I. General information

NPI: 1194761056
Provider Name (Legal Business Name): SUSANA SANTIAGO NOLASCO-ALONZO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: SUSANA NOLASCO ALONZO MD

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 W TENNYSON RD #5
HAYWARD CA
94544-4400
US

IV. Provider business mailing address

2926 MOUNTAIN DR
FREMONT CA
94555-1362
US

V. Phone/Fax

Practice location:
  • Phone: 510-782-7116
  • Fax: 510-782-4574
Mailing address:
  • Phone: 510-791-8010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA38527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: