Healthcare Provider Details

I. General information

NPI: 1811904519
Provider Name (Legal Business Name): THAWAT EOSAKUL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16860 SEVILLE AVE
FONTANA CA
92335-3561
US

IV. Provider business mailing address

16860 SEVILLE AVE
FONTANA CA
92335-3561
US

V. Phone/Fax

Practice location:
  • Phone: 909-350-3091
  • Fax: 909-350-1172
Mailing address:
  • Phone: 909-350-3091
  • Fax: 909-350-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA32349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: