Provider Demographics
NPI:1558363739
Name:ITSARA, KRIENGSAK (MD)
Entity Type:Individual
Prefix:
First Name:KRIENGSAK
Middle Name:
Last Name:ITSARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KRIENGSAK
Other - Middle Name:
Other - Last Name:ITSARAYOUNGYUEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:305 E GRANGER AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4344
Mailing Address - Country:US
Mailing Address - Phone:206-526-1606
Mailing Address - Fax:209-526-1677
Practice Address - Street 1:305 E GRANGER AVE
Practice Address - Street 2:STE 202
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4344
Practice Address - Country:US
Practice Address - Phone:206-526-1606
Practice Address - Fax:209-526-1677
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33103207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A331030Medicaid
CA00A331030Medicaid
CA00A331032Medicare PIN