Healthcare Provider Details

I. General information

NPI: 1568701209
Provider Name (Legal Business Name): MR. PHOLPHAT INPIROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 CASTLE GLEN DR UNIT 128
SAN DIEGO CA
92123-2432
US

IV. Provider business mailing address

3549 CASTLE GLEN DR UNIT 128
SAN DIEGO CA
92123-2432
US

V. Phone/Fax

Practice location:
  • Phone: 619-955-2360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number504629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: