Provider Demographics
NPI:1114169380
Name:INTISAB SULTAN,A MEDICAL PROFESSIONAL CORPORATION OF CALIFORNIA
Entity Type:Organization
Organization Name:INTISAB SULTAN,A MEDICAL PROFESSIONAL CORPORATION OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:INTISAB
Authorized Official - Middle Name:
Authorized Official - Last Name:SULTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-891-0100
Mailing Address - Street 1:2256 DOCKERY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3806
Mailing Address - Country:US
Mailing Address - Phone:559-891-0100
Mailing Address - Fax:559-891-9000
Practice Address - Street 1:2256 DOCKERY AVE STE A
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3806
Practice Address - Country:US
Practice Address - Phone:559-891-0100
Practice Address - Fax:559-891-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000A769620Medicaid
CA000A769620Medicaid