Healthcare Provider Details

I. General information

NPI: 1578704524
Provider Name (Legal Business Name): SUZANNE WALDORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST SUITE B
MODESTO CA
95350-5814
US

IV. Provider business mailing address

908 EDISON AVE
MODESTO CA
95350-5536
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax: 209-523-1296
Mailing address:
  • Phone: 209-577-8608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: