Provider Demographics
NPI:1386696185
Name:MAYO, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAYO
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:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91358-0176
Mailing Address - Country:US
Mailing Address - Phone:805-495-1066
Mailing Address - Fax:
Practice Address - Street 1:2230 LYNN RD STE 200
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1900
Practice Address - Country:US
Practice Address - Phone:805-495-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52330207R00000X
MO2018016629207R00000X
MI4301115586207R00000X
TXR8607207R00000X
CAA63489207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA63489Medicare ID - Type Unspecified
CAG89859Medicare UPIN