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General NPI Number Information
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NPI Number | 1174705560
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Entity Type | Organization
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Legal Business Name | SUSAN M KALLAL, M.D. PHARM.D., A.M.C
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Dates
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Enumeration Date | 11/28/2007
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Last Update Date | 04/13/2012
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Provider Practice Location Address
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Address Line | 10921 WILSHIRE BLVD STE 901
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City | LOS ANGELES
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State | CA
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Zip | 90024-4000
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Country | US
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Telephone | 310-828-1915
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Fax | 310-443-0474
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Provider Business Mailing Address
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Address Line | 10921 WILSHIRE BLVD STE 901
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City | LOS ANGELES
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State | CA
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Zip | 90024-4000
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Country | US
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Telephone | 310-828-1915
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Fax | 310-443-0474
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Authorized Official
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Title or Position | OWNER
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Name | MS. SUSAN M KALLAL
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Credential | M.D.
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Telephone | 310-828-1915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | A70271
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License Number State | CA
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