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NPI Code Detail

MEDICARE: SUSAN BRALLIER DO

MEDICARE: SUSAN BRALLIER DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician2439AZ
2208000000XPediatrics Physician20A10428CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
120A10428OTHERCALICENSE

General Provider Information

NPI Number : 1083627517
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN BRALLIER DO
Provider Business Mailing Address
First Line : 780 E WASHINGTON BLVD
Second Line : STE 202
City : CRESCENT CITY
State : CA
Zip : 95531-8397
Country : US
Telephone Number : 707-464-6715
Fax Number : 707-464-9593
Provider Business Practice Location Address
First Line : 780 E WASHINGTON BLVD
Second Line : STE 202
City : CRESCENT CITY
State : CA
Zip : 95531-8397
Country : US
Telephone Number : 707-464-6715
Fax Number : 707-464-9593
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/14/2006
Last Update Date : 08/05/2008

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