Provider Demographics
NPI:1194962399
Name:RODDY S SOOFERIAN MD MEDICAL CORPORATION
Entity type:Organization
Organization Name:RODDY S SOOFERIAN MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:SOOFERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-820-0013
Mailing Address - Street 1:1375 KELTON AVE
Mailing Address - Street 2:#109
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5499
Mailing Address - Country:US
Mailing Address - Phone:310-820-0013
Mailing Address - Fax:310-207-2630
Practice Address - Street 1:1375 KELTON AVE
Practice Address - Street 2:#109
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5499
Practice Address - Country:US
Practice Address - Phone:310-820-0013
Practice Address - Fax:310-207-2630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-10
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH71092Medicare UPIN