Provider Demographics
NPI:1003836610
Name:SUSANTO, IRAWAN (MD)
Entity type:Individual
Prefix:
First Name:IRAWAN
Middle Name:
Last Name:SUSANTO
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-301-8708
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:1223 16TH ST
Practice Address - Street 2:SUITE 3400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1217
Practice Address - Country:US
Practice Address - Phone:310-449-0939
Practice Address - Fax:424-259-7790
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50280207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C502800Medicaid
CAWC50280CMedicare PIN
CAD95824Medicare UPIN
CAWC50280BMedicare PIN
CAWC50280AMedicare PIN