Healthcare Provider Details

I. General information

NPI: 1295861581
Provider Name (Legal Business Name): PETEY LAOHABURANAKIT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 01/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 BRUCEVILLE RD
SACRAMENTO CA
95823-4671
US

IV. Provider business mailing address

2011 U ST
SACRAMENTO CA
95818-1771
US

V. Phone/Fax

Practice location:
  • Phone: 916-688-2000
  • Fax:
Mailing address:
  • Phone: 541-531-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD25000
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA72406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: