Provider Demographics
NPI:1447251640
Name:EHRET, SUSANNAH (MD)
Entity type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:
Last Name:EHRET
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 1:11539 HAWTHORNE BLVD
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2381
Mailing Address - Country:US
Mailing Address - Phone:310-675-5370
Mailing Address - Fax:310-531-2084
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 818
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-670-3255
Practice Address - Fax:310-531-2325
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68091208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A68091AMedicaid
WA68091AMedicare ID - Type Unspecified
H47535Medicare UPIN
CACX131ZMedicare PIN