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General NPI Number Information
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NPI Number | 1700140712
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Entity Type | Individual
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Provider Name | JUNTIRA LAOTHAVORN M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/25/2012
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Last Update Date | 12/04/2020
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Provider Practice Location Address
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Address Line | 1745 PHOENIX BLVD STE 240
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City | ATLANTA
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State | GA
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Zip | 30349-5534
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Country | US
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Telephone | 404-507-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 88 N AVONDALE RD # 181
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-1323
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Country | US
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Telephone | 404-579-4544
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 125061354
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 076279
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License Number State | GA
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