Healthcare Provider Details

I. General information

NPI: 1124680897
Provider Name (Legal Business Name): DR. TRIYUG BIKRAM MALLA THAKURI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 BROOKSHIRE AVE
DOWNEY CA
90241-4917
US

IV. Provider business mailing address

2200 COLORADO AVE APT 715
SANTA MONICA CA
90404-5534
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-5000
  • Fax: 562-904-5140
Mailing address:
  • Phone: 936-207-6093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number204703
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number000517815
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: