Healthcare Provider Details

I. General information

NPI: 1700140712
Provider Name (Legal Business Name): JUNTIRA LAOTHAVORN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 PHOENIX BLVD STE 240
ATLANTA GA
30349-5534
US

IV. Provider business mailing address

88 N AVONDALE RD # 181
AVONDALE ESTATES GA
30002-1323
US

V. Phone/Fax

Practice location:
  • Phone: 404-507-7100
  • Fax:
Mailing address:
  • Phone: 404-579-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number125061354
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number076279
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: