Provider Demographics
NPI:1972690899
Name:MED-PRO FAMILY CLINIC, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MED-PRO FAMILY CLINIC, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAYEEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULTANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-635-3800
Mailing Address - Street 1:11017 S. ATLANTIC AVE.
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-635-3800
Mailing Address - Fax:310-635-5448
Practice Address - Street 1:221 E. GLENOAKS BLVD.
Practice Address - Street 2:130
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207
Practice Address - Country:US
Practice Address - Phone:818-549-1713
Practice Address - Fax:818-549-1716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36908208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0085430Medicaid
CAW15913Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER