Healthcare Provider Details

I. General information

NPI: 1154315828
Provider Name (Legal Business Name): TANTAM MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W EDINGER AVE STE B
SANTA ANA CA
92704-4339
US

IV. Provider business mailing address

1610 W EDINGER AVE STE B
SANTA ANA CA
92704-4339
US

V. Phone/Fax

Practice location:
  • Phone: 714-641-1610
  • Fax: 714-641-1146
Mailing address:
  • Phone: 714-641-1610
  • Fax: 714-641-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA31595
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA31442
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA71362
License Number StateCA

VIII. Authorized Official

Name: DR. PUMIPAK TANTAMJARIK
Title or Position: PHYSICIAN
Credential: MD, FAAFP
Phone: 714-641-1610