Provider Demographics
NPI:1114062361
Name:SITTIPORN BOONTUNG, M.D. INC.
Entity Type:Organization
Organization Name:SITTIPORN BOONTUNG, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SITTIPORN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONTUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-530-6264
Mailing Address - Street 1:23000 CRENSHAW BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3052
Mailing Address - Country:US
Mailing Address - Phone:310-530-6264
Mailing Address - Fax:310-530-0709
Practice Address - Street 1:23000 CRENSHAW BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3052
Practice Address - Country:US
Practice Address - Phone:310-530-6264
Practice Address - Fax:310-530-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25148174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25148Medicare ID - Type Unspecified
CAB50002Medicare UPIN