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General NPI Number Information
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NPI Number | 1104978766
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Entity Type | Organization
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Legal Business Name | IMAGE M.D.
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 12805 VICTORY BLVD
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City | N HOLLYWOOD
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State | CA
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Zip | 91606-3012
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Country | US
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Telephone | 818-506-5906
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Fax |
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Provider Business Mailing Address
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Address Line | 12805 VICTORY BLVD
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City | N HOLLYWOOD
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State | CA
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Zip | 91606-3012
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Country | US
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Telephone | 818-506-5906
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN OWNER
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Name | DR. CLARENCE SUTTON
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Credential | M.D.
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Telephone | 818-506-5906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | G74582
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License Number State | CA
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