Provider Demographics
NPI:1548362296
Name:SULTAN, INTISAB (MD)
Entity type:Individual
Prefix:DR
First Name:INTISAB
Middle Name:
Last Name:SULTAN
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 1:2256 DOCKERY AVE
Mailing Address - Street 2:STE # A
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3806
Mailing Address - Country:US
Mailing Address - Phone:559-891-0100
Mailing Address - Fax:559-891-9000
Practice Address - Street 1:2256 DOCKERY AVE
Practice Address - Street 2:STE # A
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3806
Practice Address - Country:US
Practice Address - Phone:559-891-0100
Practice Address - Fax:559-891-9000
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A769620Medicaid
CA00A769620Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00A769620Medicaid