Provider Demographics
NPI:1225047509
Name:A. EBBIE SOROUDI, MD, MS A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:A. EBBIE SOROUDI, MD, MS A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A PROFESSIONAL MEDICAL CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:EBBIE
Authorized Official - Last Name:SOROUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MS
Authorized Official - Phone:310-770-7836
Mailing Address - Street 1:8900 WILSHIRE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1959
Mailing Address - Country:US
Mailing Address - Phone:310-474-2010
Mailing Address - Fax:310-474-2009
Practice Address - Street 1:8900 WILSHIRE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1959
Practice Address - Country:US
Practice Address - Phone:310-474-2010
Practice Address - Fax:310-474-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75978207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A759780Medicaid
CAW19866Medicare PIN
CA00A759780Medicaid