=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114022076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE LESLIE ROBERTS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4650 W SUNSET BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-669-2534
-----------------------------------------------------
Fax | 323-906-8003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6430 W SUNSET BLVD SUITE 600
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-669-2337
-----------------------------------------------------
Fax | 323-644-8488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | G63849
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | G63849
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------