Provider Demographics
NPI:1386810810
Name:CARSON, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2814
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:323-361-8052
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS #54
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2121
Practice Address - Fax:323-361-7128
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5444392080P0207X
CA12739363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology