Provider Demographics
NPI:1285843979
Name:KANJANAUTHAI, SOMSUPHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SOMSUPHA
Middle Name:
Last Name:KANJANAUTHAI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6098
Mailing Address - Country:US
Mailing Address - Phone:323-913-4200
Mailing Address - Fax:510-281-0766
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6098
Practice Address - Country:US
Practice Address - Phone:323-913-4200
Practice Address - Fax:510-281-0766
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103083207RI0011X, 207R00000X, 207RC0000X
WI22647207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201073310AMedicaid
KS201073310AMedicaid