Healthcare Provider Details

I. General information

NPI: 1699767400
Provider Name (Legal Business Name): SUDJAI ITSARA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUDJAI CHAIAMNUAY M.D.

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 08/31/2006

III. Provider practice location address

305 E GRANGER AVE STE 201
MODESTO CA
95350-4344
US

IV. Provider business mailing address

305 E GRANGER AVE STE 201
MODESTO CA
95350-4344
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-3336
  • Fax: 209-526-3316
Mailing address:
  • Phone: 209-526-3336
  • Fax: 209-526-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA38082
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: