Provider Demographics
NPI:1073830964
Name:BHATARAKAMOL, VEENA KULCHAIYAWAT (DO)
Entity Type:Individual
Prefix:
First Name:VEENA
Middle Name:KULCHAIYAWAT
Last Name:BHATARAKAMOL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VEENA
Other - Middle Name:
Other - Last Name:KULCHAIYAWAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1255 W ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2340
Mailing Address - Country:US
Mailing Address - Phone:800-780-1277
Mailing Address - Fax:
Practice Address - Street 1:1255 W ARROW HWY
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2340
Practice Address - Country:US
Practice Address - Phone:800-780-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-01
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine