Healthcare Provider Details

I. General information

NPI: 1457469074
Provider Name (Legal Business Name): SURASAK PHUPHANICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048
US

IV. Provider business mailing address

PO BOX 512717
LOS ANGELES CA
90051-0717
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number53514
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number53135
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA36229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: