Healthcare Provider Details

I. General information

NPI: 1700888476
Provider Name (Legal Business Name): OPAS ANOTHAYANONTHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 GRAND AVE
DES MOINES IA
50312-5305
US

IV. Provider business mailing address

2213 GRAND AVE
DES MOINES IA
50312-5305
US

V. Phone/Fax

Practice location:
  • Phone: 515-237-3974
  • Fax: 515-237-3979
Mailing address:
  • Phone: 515-237-3974
  • Fax: 515-883-2692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number18895
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: