Basic Information
| Provider Information | |||||||||
| NPI: | 1043328115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASSIDY | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 TOYON LN | ||||||||
| Address2: | |||||||||
| City: | SAUSALITO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949651826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153320588 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 FRESNO ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592274472 | ||||||||
| FaxNumber: | 5592274217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | G85862 | CA | N | Allopathic & Osteopathic Physicians | General Practice | 207SG0201X | G85862 | CA | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208000000X | G85862 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00G858620 | 05 | CA | MEDICAID |