Provider Demographics
NPI:1558182584
Name:BURKE, SUSAN A (LAC, OMD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:BURKE
Suffix:
Gender:F
Credentials:LAC, OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1603
Mailing Address - Country:US
Mailing Address - Phone:760-880-1896
Mailing Address - Fax:
Practice Address - Street 1:4141 MISSISSIPPI ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-1603
Practice Address - Country:US
Practice Address - Phone:760-880-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2992208VP0000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine