Healthcare Provider Details

I. General information

NPI: 1578730073
Provider Name (Legal Business Name): SIRIWAN MINGBUNJERDSUK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 12/17/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 COYLE AVE STE 310
CARMICHAEL CA
95608-0303
US

IV. Provider business mailing address

4029 MCCLAIN WAY APT 45
CARMICHAEL CA
95608-2485
US

V. Phone/Fax

Practice location:
  • Phone: 916-965-4612
  • Fax:
Mailing address:
  • Phone: 989-370-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA124849
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301095528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: