Provider Demographics
NPI:1114091857
Name:OM SOOD MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:OM SOOD MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OM
Authorized Official - Middle Name:PARICASH
Authorized Official - Last Name:SOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-955-2828
Mailing Address - Street 1:12998 HESPERIA RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8316
Mailing Address - Country:US
Mailing Address - Phone:760-955-2828
Mailing Address - Fax:760-955-2488
Practice Address - Street 1:12998 HESPERIA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8316
Practice Address - Country:US
Practice Address - Phone:760-955-2828
Practice Address - Fax:760-955-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101680Medicaid
CAZZZ01374ZMedicare PIN