Healthcare Provider Details

I. General information

NPI: 1114313616
Provider Name (Legal Business Name): MICHELLE SRIWONGTONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 CASTRO ST 3
SAN FRANCISCO CA
94114-2858
US

IV. Provider business mailing address

245 S FETTERLY AVE
LOS ANGELES CA
90022-1605
US

V. Phone/Fax

Practice location:
  • Phone: 415-940-0264
  • Fax:
Mailing address:
  • Phone: 323-362-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number145266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: