1699882415 NPI number — DR. KOONLAWEE NADEMANEE M.D.

Table of content: DR. KOONLAWEE NADEMANEE M.D. (NPI 1699882415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699882415 NPI number — DR. KOONLAWEE NADEMANEE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NADEMANEE
Provider First Name:
KOONLAWEE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699882415
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 33679
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90033-0679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-672-9999
Provider Business Mailing Address Fax Number:
310-861-0540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 CESAR E. CHAVEZ AVENUE
Provider Second Line Business Practice Location Address:
SUITE 2700
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90033-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-672-9999
Provider Business Practice Location Address Fax Number:
310-861-0540
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0001X , with the licence number:  A32891 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0090210 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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