MEDICARE: CLARENCE SUTTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	G74582	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G74582	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1174674774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARENCE SUTTON

Provider Business Mailing Address
First Line	:	12805 VICTORY BLVD
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91606-3012
Country	:	US
Telephone Number	:	818-506-5906
Fax Number	:

Provider Business Practice Location Address
First Line	:	12805 VICTORY BLVD
Second Line	:
City	:	N HOLLYWOOD
State	:	CA
Zip	:	91606-3012
Country	:	US
Telephone Number	:	818-506-5906
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/08/2007

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Directions to “ CLARENCE SUTTON ” Practice Location

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