Healthcare Provider Details

I. General information

NPI: 1922413038
Provider Name (Legal Business Name): PHASSARIN CHANSAKUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20101 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5305
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-866-3400
  • Fax: 510-506-7729
Mailing address:
  • Phone: 510-866-3400
  • Fax: 510-506-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA149124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: