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 1:16111 PLUMMER ST
Mailing Address - Street 2:BLDG 200, MAIL CODE OOPR
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-2036
Mailing Address - Country:US
Mailing Address - Phone:818-891-7711
Mailing Address - Fax:818-895-9452
Practice Address - Street 1:16111 PLUMMER ST
Practice Address - Street 2:BLDG 200, MAIL CODE OOPR
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-2036
Practice Address - Country:US
Practice Address - Phone:818-891-7711
Practice Address - Fax:818-895-9452
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2023-08-14
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