Healthcare Provider Details

I. General information

NPI: 1497060263
Provider Name (Legal Business Name): TANYATORN GHANJANASAK D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6768 CHESTNUT ST
CINCINNATI OH
45227-3607
US

IV. Provider business mailing address

6768 CHESTNUT ST
CINCINNATI OH
45227-3607
US

V. Phone/Fax

Practice location:
  • Phone: 858-255-9545
  • Fax:
Mailing address:
  • Phone: 858-255-9545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number902
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58.007764
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: