Healthcare Provider Details

I. General information

NPI: 1730373101
Provider Name (Legal Business Name): S PATT MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N ORANGE GROVE STE 104
POMONA CA
91767
US

IV. Provider business mailing address

1818 N ORANGE GROVE STE 104
POMONA CA
91767
US

V. Phone/Fax

Practice location:
  • Phone: 909-592-2816
  • Fax: 909-868-6967
Mailing address:
  • Phone: 909-592-2816
  • Fax: 909-868-6967

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 NumberA32823
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA32823
License Number StateCA

VIII. Authorized Official

Name: MRS. SUWAPANG PATTUMMADITH
Title or Position: PRESIDENT
Credential: MD
Phone: 909-592-2816