Provider Demographics
NPI:1346240637
Name:SACKS, ELLIOT M (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:M
Last Name:SACKS
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:DEPT LA 21789
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1789
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:800-409-7005
Practice Address - Street 1:27700 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6426
Practice Address - Country:US
Practice Address - Phone:949-263-8620
Practice Address - Fax:800-409-7005
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000284542085R0202X, 2085R0204X
CAG326572085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8126476Medicaid
CA00G326570OtherBC/BS OF CA
CA1346240637Medicaid
CA00G326570OtherBC/BS OF CA
000159721Medicare PIN
CACB224737Medicare PIN
CA1346240637Medicaid
WA8126476Medicaid