Healthcare Provider Details

I. General information

NPI: 1407276363
Provider Name (Legal Business Name): TIRANUN RUNGVIVATJARUS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5064
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5841
  • Fax:
Mailing address:
  • Phone: 858-966-5841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA141353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: