Provider Demographics
NPI:1730435280
Name:OKUNBO, TINYAN (MD)
Entity type:Individual
Prefix:
First Name:TINYAN
Middle Name:
Last Name:OKUNBO
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 1:4924 BALBOA BLVD
Mailing Address - Street 2:356
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3402
Mailing Address - Country:US
Mailing Address - Phone:818-300-4308
Mailing Address - Fax:714-280-8504
Practice Address - Street 1:820 S COTTONTAIL LN
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1409
Practice Address - Country:US
Practice Address - Phone:714-858-3109
Practice Address - Fax:714-280-8504
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50892208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice