Provider Demographics
NPI:1962551119
Name:SUSMAN, KENNETH ROGER (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROGER
Last Name:SUSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 CYPRESS ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5411
Mailing Address - Country:US
Mailing Address - Phone:707-961-1972
Mailing Address - Fax:707-961-1978
Practice Address - Street 1:510 CYPRESS ST
Practice Address - Street 2:SUITE B
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5411
Practice Address - Country:US
Practice Address - Phone:707-961-1972
Practice Address - Fax:707-961-1978
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG679520174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist