Healthcare Provider Details

I. General information

NPI: 1710132980
Provider Name (Legal Business Name): DR. MARUT K THONGCHAROEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BENEDICT DR
SAN LEANDRO CA
94577-6840
US

IV. Provider business mailing address

5870 N HIATUS RD REGIONAL ADMIN OFFICE
TAMARAC FL
33321-6424
US

V. Phone/Fax

Practice location:
  • Phone: 510-357-8300
  • Fax: 510-620-3924
Mailing address:
  • Phone: 888-447-2362
  • Fax: 865-560-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC00141591
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number251033
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: