Provider Demographics
NPI:1851497002
Name:DANIELLE BORUT MD INC SAMUEL BRUTTOMESSO MD INC ET AL PTR WHITE MEMORI
Entity Type:Organization
Organization Name:DANIELLE BORUT MD INC SAMUEL BRUTTOMESSO MD INC ET AL PTR WHITE MEMORI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BORUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-987-1200
Mailing Address - Street 1:1701 E. CESAR E. CHAVEZ AVE
Mailing Address - Street 2:SUITE 532
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:323-987-1200
Mailing Address - Fax:323-987-1212
Practice Address - Street 1:1701 E. CESAR E. CHAVEZ AVE
Practice Address - Street 2:SUITE 456
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-987-1200
Practice Address - Fax:323-987-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14545Medicare UPIN