Provider Demographics
NPI:1053428334
Name:SUTJITA, MADE (MD)
Entity type:Individual
Prefix:
First Name:MADE
Middle Name:
Last Name:SUTJITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7270
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-7270
Mailing Address - Country:US
Mailing Address - Phone:951-656-1500
Mailing Address - Fax:951-656-1510
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5700
Practice Address - Fax:951-486-5705
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA77694207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98429Medicare UPIN