=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720309420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRASHANTH SUTRAVE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2010
-----------------------------------------------------
Last Update Date | 08/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3630 E IMPERIAL HWY
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-900-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3129
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90510-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
Fax | 855-898-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 54022-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207LC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | 54022-20
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 258325
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | C156219
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------