MEDICARE: RODDY S SOOFERIAN MD MEDICAL CORPORATION

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	207R00000X	Internal Medicine Physician	A76881	CA

General Provider Information

NPI Number	:	1194962399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RODDY S SOOFERIAN MD MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	1375 KELTON AVE
Second Line	:	#109
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-5499
Country	:	US
Telephone Number	:	310-820-0013
Fax Number	:	310-207-2630

Provider Business Practice Location Address
First Line	:	1375 KELTON AVE
Second Line	:	#109
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-5499
Country	:	US
Telephone Number	:	310-820-0013
Fax Number	:	310-207-2630

Authorized Official
Title or Position	:	CEO
Name	:	RODDY S. SOOFERIAN
Credential	:	M.D.
Telephone Number	:	310-820-0013

Provider Enumeration Date	:	01/10/2009
Last Update Date	:	01/28/2009

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