Healthcare Provider Details

I. General information

NPI: 1336296565
Provider Name (Legal Business Name): SUSANA SANTIAGO-SORIANO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 BEVERLY BLVD
LOS ANGELES CA
90004-3407
US

IV. Provider business mailing address

3908 BEVERLY BLVD
LOS ANGELES CA
90004-3407
US

V. Phone/Fax

Practice location:
  • Phone: 213-388-2508
  • Fax: 213-388-5377
Mailing address:
  • Phone: 213-388-2508
  • Fax: 213-388-5377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA68987
License Number StateCA

VIII. Authorized Official

Name: DR. SUSANA VISDA SANTIAGO-SORIANO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-388-2508