Healthcare Provider Details

I. General information

NPI: 1013091388
Provider Name (Legal Business Name): SUSAN I GOLDWASSER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 PASEO MIRASOL
TIBURON CA
94920-2021
US

IV. Provider business mailing address

38 PASEO MIRASOL
TIBURON CA
94920-2021
US

V. Phone/Fax

Practice location:
  • Phone: 415-507-2537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG68836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: