Provider Demographics
NPI:1124073374
Name:SULAM, DAVID (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SULAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 YORK BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2634
Mailing Address - Country:US
Mailing Address - Phone:323-255-5643
Mailing Address - Fax:323-254-2158
Practice Address - Street 1:5823 YORK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-2634
Practice Address - Country:US
Practice Address - Phone:323-255-1575
Practice Address - Fax:323-254-2158
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G590290OtherBLUE SHIELD
CA00G590290Medicaid
CAWG59029FMedicare PIN
CA00G590290Medicaid