Provider Demographics
NPI:1164955977
Name:SOROUDI, CAMILLE
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:SOROUDI
Suffix:
Gender:F
Credentials:
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:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:700 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3768
Practice Address - Country:US
Practice Address - Phone:310-988-8380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA163148207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA163148OtherSTATE LICENSE
CAFS8953564OtherDEA