Healthcare Provider Details

I. General information

NPI: 1700061298
Provider Name (Legal Business Name): S PATT MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3621 E MLK JR BL #14
LYNWOOD CA
90262
US

IV. Provider business mailing address

3621 E MLK JR BL #14
LYNWOOD CA
90262
US

V. Phone/Fax

Practice location:
  • Phone: 310-537-5810
  • Fax: 310-537-5876
Mailing address:
  • Phone: 310-537-5810
  • Fax: 310-537-5876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA32823
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. SUWAPANG PATTAMMADITH
Title or Position: DERMATOLOGIST
Credential: MD
Phone: 310-537-5810