Healthcare Provider Details

I. General information

NPI: 1205856804
Provider Name (Legal Business Name): SAMUEL A SKOOTSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA #365,530,420,120
LOS ANGELES CA
90095
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-4646
  • Fax: 310-267-2571
Mailing address:
  • Phone: 310-301-5203
  • Fax: 310-301-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG43765
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: