Provider Demographics
NPI:1104978766
Name:IMAGE M.D.
Entity type:Organization
Organization Name:IMAGE M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-506-5906
Mailing Address - Street 1:12805 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:N HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3012
Mailing Address - Country:US
Mailing Address - Phone:818-506-5906
Mailing Address - Fax:
Practice Address - Street 1:12805 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3012
Practice Address - Country:US
Practice Address - Phone:818-506-5906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74582208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherEIN