Healthcare Provider Details

I. General information

NPI: 1144756677
Provider Name (Legal Business Name): CHALEE YIMYAM D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-2205
US

IV. Provider business mailing address

330 13TH ST APT 2207
SAN DIEGO CA
92101-4762
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-1707
  • Fax:
Mailing address:
  • Phone: 253-600-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number5976
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3948
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number11694035-0501
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberE5976
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: