Provider Demographics
NPI:1306073994
Name:MORDO SUCHOV M D INC
Entity type:Organization
Organization Name:MORDO SUCHOV M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MORDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUCHOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-905-1567
Mailing Address - Street 1:16260 VENTURA BLVD
Mailing Address - Street 2:SUITE LL-15
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2203
Mailing Address - Country:US
Mailing Address - Phone:818-905-1567
Mailing Address - Fax:818-905-7406
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:SUITE LL-15
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:818-905-1567
Practice Address - Fax:818-905-7406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39778207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare UPIN