Provider Demographics
NPI:1154834075
Name:RATHANANAKINTARA, THAWORN (MD)
Entity Type:Individual
Prefix:
First Name:THAWORN
Middle Name:
Last Name:RATHANANAKINTARA
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 1:11445 DONA DOLORES PL
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-4240
Mailing Address - Country:US
Mailing Address - Phone:323-650-6276
Mailing Address - Fax:
Practice Address - Street 1:6838 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-7008
Practice Address - Country:US
Practice Address - Phone:323-461-3161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA307952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry