Healthcare Provider Details

I. General information

NPI: 1083092753
Provider Name (Legal Business Name): IDA TUWATANANURAK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W 6TH ST STE 200
LOS ANGELES CA
90020-5108
US

IV. Provider business mailing address

3727 W 6TH ST STE 210
LOS ANGELES CA
90020-5108
US

V. Phone/Fax

Practice location:
  • Phone: 213-235-2500
  • Fax: 213-251-8647
Mailing address:
  • Phone: 213-235-2500
  • Fax: 213-427-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT016449
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A16453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: