Provider Demographics
NPI:1114905502
Name:SUDJIAN, ELENA VASIL (MD)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:VASIL
Last Name:SUDJIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:KRET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2315 STOCKTON BLVD STE 2P101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-734-7506
Mailing Address - Fax:916-734-4810
Practice Address - Street 1:4150 V STREET
Practice Address - Street 2:SUITE 3400
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-7506
Practice Address - Fax:916-734-4810
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69477208M00000X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A694770Medicaid
H17876Medicare UPIN
00A694770Medicare ID - Type Unspecified