Provider Demographics
NPI:1548387095
Name:SASU, SEBASTIAN JOHNSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:JOHNSON
Last Name:SASU
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 1:1328 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2032
Mailing Address - Country:US
Mailing Address - Phone:310-829-8101
Mailing Address - Fax:310-829-6509
Practice Address - Street 1:1328 22ND ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2032
Practice Address - Country:US
Practice Address - Phone:310-829-8101
Practice Address - Fax:310-829-6509
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89268207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A892680Medicaid
CAI74086Medicare UPIN
CAWA89268AMedicare PIN