Healthcare Provider Details

I. General information

NPI: 1457598716
Provider Name (Legal Business Name): SUVANNEE VIDHYAPUM M.D.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2009
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 HILLHURST AVE
LOS ANGELES CA
90027-5516
US

IV. Provider business mailing address

1530 HILLHURST AVE
LOS ANGELES CA
90027-5516
US

V. Phone/Fax

Practice location:
  • Phone: 323-644-3880
  • Fax: 323-644-3892
Mailing address:
  • Phone: 323-644-3880
  • Fax: 323-644-3892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA37684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: