Healthcare Provider Details

I. General information

NPI: 1427085810
Provider Name (Legal Business Name): PORNCHAI TIRAKITSOONTORN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S MAIN ST
ORANGE CA
92868-3835
US

IV. Provider business mailing address

455 S MAIN ST
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-289-3212
  • Fax: 714-204-3212
Mailing address:
  • Phone: 714-289-3212
  • Fax: 714-204-3212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberA64929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: