Healthcare Provider Details

I. General information

NPI: 1093864373
Provider Name (Legal Business Name): SOE TIN MAUNGLAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/08/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 316
RIVERSIDE CA
92501-4090
US

IV. Provider business mailing address

51753 EL DORADO DR
LA QUINTA CA
92253-9034
US

V. Phone/Fax

Practice location:
  • Phone: 951-394-3055
  • Fax: 951-394-3077
Mailing address:
  • Phone: 760-619-2309
  • Fax: 866-428-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberC152411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: