Provider Demographics
NPI:1578564902
Name:PATTANUMOTANA, DAMRONG (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMRONG
Middle Name:
Last Name:PATTANUMOTANA
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 1:2033 DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2013
Mailing Address - Country:US
Mailing Address - Phone:559-266-6735
Mailing Address - Fax:559-266-2207
Practice Address - Street 1:2033 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2013
Practice Address - Country:US
Practice Address - Phone:559-266-6735
Practice Address - Fax:559-266-2207
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA039363207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A393630Medicaid
CAA28878Medicare UPIN
CA00A393630Medicare ID - Type Unspecified