Healthcare Provider Details

I. General information

NPI: 1366974743
Provider Name (Legal Business Name): JOYCE ANGELINE SUTEDJA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W SUITE 1400
ORANGE CA
92868-2903
US

IV. Provider business mailing address

1149 MIRA MAR AVE
LONG BEACH CA
90804-4139
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5616
  • Fax: 714-456-8360
Mailing address:
  • Phone: 323-819-6021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA159065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: