Provider Demographics
NPI:1669406468
Name:BRUTTOMESSO, SAMUEL D (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:D
Last Name:BRUTTOMESSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
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:90033-2464
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:90033-2464
Practice Address - Country:US
Practice Address - Phone:323-987-1200
Practice Address - Fax:323-987-1212
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG22043208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90740Medicare UPIN