MEDICARE: SUSAN J MACKENSEN M.D.

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
1	208000000X	Pediatrics Physician	AFE46013	CA

General Provider Information

NPI Number	:	1659309896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN J MACKENSEN M.D.

Provider Business Mailing Address
First Line	:	1809 PREUSS RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4313
Country	:	US
Telephone Number	:	310-838-3092
Fax Number	:	310-287-0656

Provider Business Practice Location Address
First Line	:	1809 PREUSS RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-4313
Country	:	US
Telephone Number	:	310-838-3092
Fax Number	:	310-287-0656

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	03/24/2014

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