Healthcare Provider Details

I. General information

NPI: 1124362546
Provider Name (Legal Business Name): TIN MOE SAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 W SUNSET BLVD
LOS ANGELES CA
90027-5716
US

IV. Provider business mailing address

5255 W SUNSET BLVD
LOS ANGELES CA
90027-5716
US

V. Phone/Fax

Practice location:
  • Phone: 323-463-7262
  • Fax:
Mailing address:
  • Phone: 323-463-7262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA.124282
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: