1114905502 NPI number — DR. ELENA VASIL SUDJIAN MD

Table of content: DR. ELENA VASIL SUDJIAN MD (NPI 1114905502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114905502 NPI number — DR. ELENA VASIL SUDJIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUDJIAN
Provider First Name:
ELENA
Provider Middle Name:
VASIL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRET
Provider Other First Name:
ELENA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114905502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 STOCKTON BLVD STE 2P101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95817-2201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-734-7506
Provider Business Mailing Address Fax Number:
916-734-4810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4150 V STREET
Provider Second Line Business Practice Location Address:
SUITE 3400
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-7506
Provider Business Practice Location Address Fax Number:
916-734-4810
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  A69477 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A69477 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A694770 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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