Healthcare Provider Details

I. General information

NPI: 1841793619
Provider Name (Legal Business Name): ANDREW JEREMY DARMAHKASIH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2018
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 FAIRMOUNT AVE STE 310
PASADENA CA
91105-3153
US

IV. Provider business mailing address

800 FAIRMOUNT AVE STE 310
PASADENA CA
91105-3153
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-7350
  • Fax: 626-449-1321
Mailing address:
  • Phone: 626-449-7350
  • Fax: 626-449-1321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA164751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: