Basic Information
| Provider Information | |||||||||
| NPI: | 1588007678 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARBUTT | ||||||||
| FirstName: | SUSANA | ||||||||
| MiddleName: | INES SMITH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2350 W EL CAMINO REAL FL 2 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940406203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102041844 | ||||||||
| FaxNumber: | 5105067729 | ||||||||
| Practice Location | |||||||||
| Address1: | 20101 LAKE CHABOT RD FL 4 | ||||||||
| Address2: | |||||||||
| City: | CASTRO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102041844 | ||||||||
| FaxNumber: | 5105067729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A136741 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | A136741 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RE0101X | 92819 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | FH6125783 | 01 | CA | FEDERAL DEA LICENSE | OTHER | A136741 | 01 | CA | STATE MEDICAL LICENSE | OTHER |