Provider Demographics
NPI:1609941301
Name:SUCHOV, MORDO (MD)
Entity Type:Individual
Prefix:
First Name:MORDO
Middle Name:
Last Name:SUCHOV
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 1:16260 VENTURA BLVD
Mailing Address - Street 2:SUITE LL-15
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2203
Mailing Address - Country:US
Mailing Address - Phone:818-905-1567
Mailing Address - Fax:818-905-7644
Practice Address - Street 1:850 S ATLANTIC BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-6706
Practice Address - Country:US
Practice Address - Phone:213-483-4500
Practice Address - Fax:213-483-4522
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39778207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01185FMedicaid
CAGR0064560Medicaid
A85332Medicare UPIN
W3429Medicare ID - Type Unspecified
CASUR01185FMedicaid