Provider Demographics
NPI:1568463537
Name:SATOU, GARY MARK (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARK
Last Name:SATOU
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 1:10833 LE CONTE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-5296
Mailing Address - Fax:310-825-9524
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-825-5296
Practice Address - Fax:310-825-9524
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2139232080P0202X
CAG80952080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001405267Medicaid
NY01981066Medicaid
CT001405267Medicaid
NY01981066Medicaid