Provider Demographics
NPI:1619243805
Name:KISRA, SOOD (MD)
Entity type:Individual
Prefix:
First Name:SOOD
Middle Name:
Last Name:KISRA
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 1:1800 WESTERN AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1354
Mailing Address - Country:US
Mailing Address - Phone:909-713-2323
Mailing Address - Fax:909-340-4421
Practice Address - Street 1:1800 WESTERN AVE STE 302
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1354
Practice Address - Country:US
Practice Address - Phone:909-713-2323
Practice Address - Fax:909-340-4421
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-01
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA135006207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty