Provider Demographics
NPI:1558686816
Name:CARRE, SUSAN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:CARRE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:BASULTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5900
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 1300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5312
Practice Address - Country:US
Practice Address - Phone:323-442-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine