Healthcare Provider Details

I. General information

NPI: 1376534628
Provider Name (Legal Business Name): LUCY E SUWARSA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 WARNER AVE
FOUNTAIN VALLEY CA
92708-2529
US

IV. Provider business mailing address

2742 DOW AVE
TUSTIN CA
92780-7242
US

V. Phone/Fax

Practice location:
  • Phone: 714-549-1300
  • Fax: 714-433-3100
Mailing address:
  • Phone: 714-665-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG64329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: