Provider Demographics
NPI:1407953029
Name:BACCHUS, SOROYA MONTEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:SOROYA
Middle Name:MONTEZ
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 PARK TER STE 530B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1543
Mailing Address - Country:US
Mailing Address - Phone:310-895-2541
Mailing Address - Fax:310-895-2895
Practice Address - Street 1:6801 PARK TER STE 530B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1543
Practice Address - Country:US
Practice Address - Phone:310-895-2541
Practice Address - Fax:310-895-2895
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG742462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG74246OtherMEDICAL LICENSE
CAG74246OtherMEDICAL LICENSE
CAF59597Medicare UPIN