Healthcare Provider Details

I. General information

NPI: 1083879084
Provider Name (Legal Business Name): SUTTIRAK CHAIWONGKARJOHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2008
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45104 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

45104 10TH ST W
LANCASTER CA
93534-2310
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-2391
  • Fax:
Mailing address:
  • Phone: 661-942-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA115809
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA115809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: