Healthcare Provider Details

I. General information

NPI: 1639100662
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA INFECTIOUS DISEASE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 TOWNSGATE RD SUITE 100
WESTLAKE VILLAGE CA
91361-5986
US

IV. Provider business mailing address

PO BOX 2190
LA HABRA CA
90632-2190
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-0901
  • Fax: 213-483-6650
Mailing address:
  • Phone: 213-483-0901
  • Fax: 213-483-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberW11997
License Number StateCA

VIII. Authorized Official

Name: SUMAN RADHAKRISHNA
Title or Position: MD/PARTNER
Credential: MD
Phone: 213-483-0901