Healthcare Provider Details

I. General information

NPI: 1790957504
Provider Name (Legal Business Name): SUSAN LAUREN RUSNACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 08/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST SUITE 715E
LOS ANGELES CA
90048-5901
US

IV. Provider business mailing address

8631 W 3RD ST SUITE 715E
LOS ANGELES CA
90048-5901
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-8330
  • Fax: 310-278-7595
Mailing address:
  • Phone: 310-278-8330
  • Fax: 310-278-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number236481
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC128392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: