Healthcare Provider Details

I. General information

NPI: 1508828856
Provider Name (Legal Business Name): SRIVIMOL TANTAMJARIK M.D., F.A.A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
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 TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA31595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: