Provider Demographics
NPI:1164793816
Name:PHUVADAKORN, CHAIVAT (MD)
Entity type:Individual
Prefix:
First Name:CHAIVAT
Middle Name:
Last Name:PHUVADAKORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 E MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-2607
Mailing Address - Country:US
Mailing Address - Phone:424-236-2767
Mailing Address - Fax:213-253-5017
Practice Address - Street 1:351 E TEMPLE ST
Practice Address - Street 2:MAIL CODE LAACC HOME BASED PRIMARY CARE A127A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3328
Practice Address - Country:US
Practice Address - Phone:213-253-5018
Practice Address - Fax:213-253-5018
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122504207R00000X
CA122504207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA113865OtherSID # 113865