Healthcare Provider Details

I. General information

NPI: 1619808201
Provider Name (Legal Business Name): DR. DAVID TJAHJONO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 SOUTHGATE AVE APT 103
DALY CITY CA
94015-4019
US

IV. Provider business mailing address

1450 SOUTHGATE AVE APT 103
DALY CITY CA
94015-4019
US

V. Phone/Fax

Practice location:
  • Phone: 628-666-7516
  • Fax:
Mailing address:
  • Phone: 628-666-7516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0-543-497-2
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: