Basic Information
| Provider Information | |||||||||
| NPI: | 1811184039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUCHOWIECKY | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ST PAUL AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900172038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134826400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 47825 OASIS ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922016950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608638455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2007 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | F2956 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | C54054 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 115032802 | 05 | TX | MEDICAID | 87W480 | 01 | TX | BLUE CROSS BLUE SHIELD TX | OTHER | 10021259 | 01 | TX | AMERIGROUP | OTHER |