Healthcare Provider Details

I. General information

NPI: 1386030955
Provider Name (Legal Business Name): STEPHANIE TANGSOMBATVISIT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST FL 4
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

3505 BROADWAY
OAKLAND CA
94611-5714
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-8339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberA146823
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA146823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: