Provider Demographics
NPI:1336256585
Name:ZACHARIAH, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ZACHARIAH
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 1:24551 RAYMOND WAY
Mailing Address - Street 2:STE 140
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630
Mailing Address - Country:US
Mailing Address - Phone:949-583-0975
Mailing Address - Fax:949-583-7973
Practice Address - Street 1:24551 RAYMOND WAY
Practice Address - Street 2:STE 140
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630
Practice Address - Country:US
Practice Address - Phone:949-583-0975
Practice Address - Fax:949-583-7973
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAA0427242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A427241Medicaid
CAA42724Medicare ID - Type Unspecified