Healthcare Provider Details

I. General information

NPI: 1245201201
Provider Name (Legal Business Name): SUSAN AUCOTT BALLAGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST # 3 DEPARTMENT OF OBSTETRICS & GYNECOLOGY
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

1000 W CARSON ST # 3 DEPARTMENT OF OBSTETRICS & GYNECOLOGY
TORRANCE CA
90502-2004
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-3544
  • Fax: 310-782-8148
Mailing address:
  • Phone: 310-222-3544
  • Fax: 310-782-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101056727
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number0101056727
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG62297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: