Healthcare Provider Details

I. General information

NPI: 1447251640
Provider Name (Legal Business Name): SUSANNAH EHRET MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD SUITE 818
LOS ANGELES CA
90045-3807
US

IV. Provider business mailing address

11539 HAWTHORNE BLVD 6TH FLOOR
HAWTHORNE CA
90250-2381
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-3255
  • Fax: 310-531-2325
Mailing address:
  • Phone: 310-675-5370
  • Fax: 310-531-2084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA68091
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA68091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: