Provider Demographics
NPI:1154516243
Name:SUSAN KAWESKI, M.D. A PROFESSIONAL
Entity type:Organization
Organization Name:SUSAN KAWESKI, M.D. A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAWESKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-464-9876
Mailing Address - Street 1:8415 GRANT AVE.
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941
Mailing Address - Country:US
Mailing Address - Phone:619-464-9876
Mailing Address - Fax:619-464-9877
Practice Address - Street 1:8415 GRANT AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5303
Practice Address - Country:US
Practice Address - Phone:619-464-9876
Practice Address - Fax:619-464-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP163644Medicaid
CA1629076856OtherNPI
CACGP163644Medicaid
CAW17191Medicare PIN