Provider Demographics
NPI:1982797593
Name:UMAR, SANUSI HAMBALI (MD)
Entity type:Individual
Prefix:DR
First Name:SANUSI
Middle Name:HAMBALI
Last Name:UMAR
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 1:819 N HARBOR DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2006
Mailing Address - Country:US
Mailing Address - Phone:310-480-0490
Mailing Address - Fax:310-318-1590
Practice Address - Street 1:819 N HARBOR DR
Practice Address - Street 2:SUITE 400
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2006
Practice Address - Country:US
Practice Address - Phone:310-480-0490
Practice Address - Fax:310-318-1590
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067317207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA067317OtherCALIFORNIA STATE LICENSE
CAG75373Medicare UPIN