Provider Demographics
NPI:1578851747
Name:SURA PEDIATRIC SPECIALIST, INC
Entity Type:Organization
Organization Name:SURA PEDIATRIC SPECIALIST, INC
Other - Org Name:SURA PEDIATRIC SPECIALIST, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANJANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-584-8881
Mailing Address - Street 1:7400 WALNUT PARK
Mailing Address - Street 2:SUITE # B
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5739
Mailing Address - Country:US
Mailing Address - Phone:323-584-8881
Mailing Address - Fax:323-584-8882
Practice Address - Street 1:7400 PACIFIC BLVD
Practice Address - Street 2:SUITE # B
Practice Address - City:WALNUT PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5739
Practice Address - Country:US
Practice Address - Phone:323-584-8881
Practice Address - Fax:323-584-8882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MULTI-CULTURAL MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30390208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty