Healthcare Provider Details

I. General information

NPI: 1437296431
Provider Name (Legal Business Name): MA SOMSOUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE # 3D-2 BOX 0862
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

1001 POTRERO AVE # 3D-2 BOX 0862
SAN FRANCISCO CA
94110-3518
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-8823
  • Fax: 415-641-0745
Mailing address:
  • Phone: 415-206-8823
  • Fax: 415-641-0745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA84310
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA84310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: