Healthcare Provider Details

I. General information

NPI: 1518021575
Provider Name (Legal Business Name): MARK N SUSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NORTH 10TH STREET
SANTA PAULA CA
93060
US

IV. Provider business mailing address

3418 LOMA VISTA RD STE A
VENTURA CA
93003
US

V. Phone/Fax

Practice location:
  • Phone: 805-933-8600
  • Fax: 805-933-8664
Mailing address:
  • Phone: 805-642-8565
  • Fax: 805-642-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG24121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: