Provider Demographics
NPI:1598952590
Name:QUYNH L SEBASTIAN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:QUYNH L SEBASTIAN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:QUYNH
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-917-4433
Mailing Address - Street 1:1260 15TH ST
Mailing Address - Street 2:SUITE 709
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1135
Mailing Address - Country:US
Mailing Address - Phone:310-917-4433
Mailing Address - Fax:310-917-4432
Practice Address - Street 1:1260 15TH ST
Practice Address - Street 2:SUITE 709
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1135
Practice Address - Country:US
Practice Address - Phone:310-917-4433
Practice Address - Fax:310-917-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64443207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18517OtherMEDICARE GROUP ID
CAH21399Medicare UPIN
CAWA64443AMedicare PIN