Provider Demographics
NPI:1508237207
Name:TAESOMBAT, WIPUSIT (MD)
Entity Type:Individual
Prefix:
First Name:WIPUSIT
Middle Name:
Last Name:TAESOMBAT
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 1:301 JUDAH ST
Mailing Address - Street 2:APT# 203
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2456
Mailing Address - Country:US
Mailing Address - Phone:415-758-8681
Mailing Address - Fax:
Practice Address - Street 1:521 PARNASSUS AVE
Practice Address - Street 2:C-341
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2206
Practice Address - Country:US
Practice Address - Phone:415-476-0762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF387208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery