Healthcare Provider Details

I. General information

NPI: 1508048273
Provider Name (Legal Business Name): OPAS & PUANGTONG JUTABHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

394 N CENTRAL BLVD
QUARTZSITE AZ
85346-1499
US

IV. Provider business mailing address

PO BOX 1499
QUARTZSITE AZ
85346-1499
US

V. Phone/Fax

Practice location:
  • Phone: 928-927-5454
  • Fax: 927-928-3303
Mailing address:
  • Phone: 928-927-5454
  • Fax: 928-927-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11855
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11915
License Number StateAZ

VIII. Authorized Official

Name: DR. PUANGTONG JUTABHA
Title or Position: OWNER
Credential: M.D.
Phone: 928-927-5454