Provider Demographics
NPI:1043328115
Name:CASSIDY, SUZANNE B (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:B
Last Name:CASSIDY
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 1:66 TOYON LN
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1826
Mailing Address - Country:US
Mailing Address - Phone:415-332-0588
Mailing Address - Fax:
Practice Address - Street 1:2900 FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1439
Practice Address - Country:US
Practice Address - Phone:559-227-4472
Practice Address - Fax:559-227-4217
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85862208D00000X, 207SG0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G858620Medicaid
CA00G858620Medicaid
CAPENDINGMedicare ID - Type Unspecified