Provider Demographics
NPI:1174705560
Name:SUSAN M KALLAL, M.D. PHARM.D., A.M.C
Entity type:Organization
Organization Name:SUSAN M KALLAL, M.D. PHARM.D., A.M.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KALLAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-1915
Mailing Address - Street 1:10921 WILSHIRE BLVD STE 901
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4000
Mailing Address - Country:US
Mailing Address - Phone:310-828-1915
Mailing Address - Fax:310-443-0474
Practice Address - Street 1:10921 WILSHIRE BLVD STE 901
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4000
Practice Address - Country:US
Practice Address - Phone:310-828-1915
Practice Address - Fax:310-443-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70271207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19750Medicare PIN