Provider Demographics
NPI:1194831263
Name:SUGERMAN, JAY LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:LAWRENCE
Last Name:SUGERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S ALVARADO ST
Mailing Address - Street 2:SUITE 717
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2390
Mailing Address - Country:US
Mailing Address - Phone:213-989-6959
Mailing Address - Fax:213-989-2012
Practice Address - Street 1:201 S ALVARADO ST
Practice Address - Street 2:SUITE 717
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2390
Practice Address - Country:US
Practice Address - Phone:213-989-6959
Practice Address - Fax:213-989-2012
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD22924207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00D229240Medicaid
CAWA22924CMedicare ID - Type Unspecified
CA00D229240Medicaid