Provider Demographics
NPI:1356633374
Name:MEKPONGSATORN, BERT
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:
Last Name:MEKPONGSATORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13012 VALLEYHEART DR.
Mailing Address - Street 2:1
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604
Mailing Address - Country:US
Mailing Address - Phone:818-674-0732
Mailing Address - Fax:
Practice Address - Street 1:13012 VALLEYHEART DR
Practice Address - Street 2:1
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-1975
Practice Address - Country:US
Practice Address - Phone:818-674-0732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA710647390200000X
CA4101367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program