Basic Information
| Provider Information | |||||||||
| NPI: | 1417954793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEISNER | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 W SUNFLOWER AVE. | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146198777 | ||||||||
| FaxNumber: | 7146198770 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 W. SUNFLOWER AVE. | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146198777 | ||||||||
| FaxNumber: | 7146198770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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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 | 207Q00000X | C41820 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00C418200 | 01 | CA | MEDI CAL | OTHER |