Provider Demographics
NPI:1700807609
Name:SO, DORA H (MD)
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:H
Last Name:SO
Suffix:
Gender:F
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 STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4323 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4044
Practice Address - Country:US
Practice Address - Phone:818-556-2700
Practice Address - Fax:818-295-3450
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54106207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2105021Medicaid
462213OtherTUFTS
412496OtherRIBCHIP
MAJ28938OtherMABC
96056OtherFALLON
AA38564OtherHPHC
5276624OtherCIGNA
MA000000030969OtherBMC HEALTHNET
462213OtherTUFTS
MAA38984Medicare ID - Type Unspecified