Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | A122504 | CA |
N | 111NI0900X | Internist | A122504 | CA |
Y | 207RG0300X | Geriatric Medicine | 122504 | CA |
NPI | 1164793816 |
---|---|
Provider Name | Chaivat Phuvadakorn |
First Address | North Hills, CA 91343-2036 |
Second Address | North Hills, CA 91343-2036 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2012 |
Last Update Date | 01/02/2017 |