1194831263 NPI number — JAY LAWRENCE SUGERMAN MD

Table of content: JAY LAWRENCE SUGERMAN MD (NPI 1194831263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194831263 NPI number — JAY LAWRENCE SUGERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUGERMAN
Provider First Name:
JAY
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194831263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 S ALVARADO ST
Provider Second Line Business Mailing Address:
SUITE 717
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90057-2390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-989-6959
Provider Business Mailing Address Fax Number:
213-989-2012

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S ALVARADO ST
Provider Second Line Business Practice Location Address:
SUITE 717
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90057-2390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-989-6959
Provider Business Practice Location Address Fax Number:
213-989-2012
Provider Enumeration Date:
08/22/2006

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: 207R00000X , with the licence number:  D22924 , 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: 00D229240 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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