Healthcare Provider Details

I. General information

NPI: 1124199161
Provider Name (Legal Business Name): PRANEE TULYATHAN-UNIAT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRANEE TULYATHAN MD

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

1301 CALIFORNIA ST
REDLANDS CA
92374-2910
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-3910
  • Fax:
Mailing address:
  • Phone: 909-809-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG57940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: