Provider Demographics
NPI:1215315858
Name:GILLIS, SUSAN ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:GILLIS
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 1:3200 PASEO VILLAGE WAY APT 1321
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3232
Mailing Address - Country:US
Mailing Address - Phone:260-241-5700
Mailing Address - Fax:
Practice Address - Street 1:25500 RANCHO NIGUEL RD STE 110
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-7373
Practice Address - Country:US
Practice Address - Phone:949-448-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA172110208000000X
390200000X
VA0101264528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty