Provider Demographics
NPI:1053610824
Name:DOUGLAS, SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 VIA SAN REMO
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5374
Mailing Address - Country:US
Mailing Address - Phone:310-701-2155
Mailing Address - Fax:
Practice Address - Street 1:21 VIA SAN REMO
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-5374
Practice Address - Country:US
Practice Address - Phone:310-701-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-19
Last Update Date:2011-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0520622084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology